Surgery For Heart Disease Research Articles

33-year follow-up after valvular surgery for carcinoid heart disease

Abstract Background Valvular surgery for carcinoid heart disease (CaHD) has been found to improve long-term prognosis. Experience is limited and questions about single versus double-valve surgery as well as selection of prosthetic valves remain under debate. Purpose We reviewed the surgical experience after valvular surgery for CaHD in our institution, which is a national referral center. Methods We reviewed clinical records and echocardiograms. Perioperative death was defined as mortality within 30 days of operation. Results Sixty consecutive patients (32 men, 62±9 years) underwent valve surgery between 1986 and 2019, of whom 59/60 had an intestinal carcinoid disease with hepatic metastases. Mean time from diagnosis to heart surgery was 3.8±3.7 years. Preoperatively, 6 patients were in NYHA class I/II, the others were in class III or IV. All 60 surgical procedures involved tricuspid valve replacement (TVR). In 47 cases, the pulmonary valve was treated surgically: Early in the series, five patients underwent pulmonary valvotomy or commissurotomy, and more recently, 42 patients received pulmonary valve replacement (PVR). All valves were replaced with bioprostheses, except for one pulmonary homograft. Concomitant significant aortic and mitral regurgitation occurred in 2 patients who received quadruple valve replacement. Two re-operations were performed due to degeneration of bioprostheses. Mean hospital stay was 13±9 days. Overall 30-day mortality was 11.6% (n=7) but was reduced to 8.3% in the last decade. The overall median survival was 2.2 years. Maximal survival free of reoperation was 18 years, and maximal survival for a single patient was 21 years. Median survival for combined TVR and PVR was significantly better than for single TVR or TVR combined with pulmonary valvotomy (3.0 years vs. 0.94 years, respectively, p=0.02; see Figure). Preoperatively, left ventricular ejection fraction (EF) was normal in 83%. Severe tricuspid regurgitation was always present. The right ventricle (RV) was dilated (RVD1 49 mm ± 5 mm) as well as the right atrium (60±16 ml/m2). The TAPSE was in normal range (17 to 29 mm). Pulmonary regurgitation was mild, moderate, severe, or indeterminate in 6%, 26%, 51%, and 17% respectively. In 17% the transpulmonary velocity was >2.5 m/s, indicating stenosis. On last available postoperative echo (mean time 2.1 years) EF was found unchanged. RV diameter was nearly normalized (RVD1 41 mm ± 5 mm). TAPSE was reduced (12 mm ± 4 mm). No significant regurgitation was detected in any TVR. There was significant stenosis (mean gradient >5 mmHg) in 23% of the TVR. No regurgitation of significance was detected in any PVR. A mean gradient >20 mmHg was found in 11% of the PVR. Conclusions While perioperative risk of valve replacement in CaHD remains substantial, this study shows relatively favourable outcomes of surgical valve replacement with bioprostheses. PVR together with TVR had better outcomes than those undergoing TVR only. Figure. Survival by Surgical Treatment. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Department of Medical Sciences, Uppsala University. Department of Surgical Sciences, Uppsala University

Open heart surgery or echocardiographic transthoracic or percutaneous closure in secundum atrial septal defect: a developing approach in one Chinese hospital

BackgroundTo study the clinical manifestations and advantages of open-heart surgery and echocardiographic transthoracic or percutaneous closure with secundum atrial septal defect (ASD). The surgeon’s learning curve was also analyzed.MethodsIn all, 115 consecutive patients with ASD from May 2013 to May 2019 were enrolled. According to the operative procedure, patients were divided into three groups: group one (open repair group) (n = 24), where patients underwent ASD repair (ASDR) under cardiopulmonary bypass (CPB); group two (closed surgical device closure group) (n = 69), where patients (six patients ≤1 y and sixteen ≤10 kg) underwent transthoracic ASD occlusion under transesophageal echocardiographic (TEE) guidance; and group three (transcatheter occlusion group) (n = 22), where patients underwent percutaneous ASD occlusion under echocardiography. The clinical features and results of each group were analyzed. All patients were telephonically followed-up after 3 months.ResultsAll the three methods treating ASD were successfully performed in our hospital. It was also a typical developing history of congenital heart disease (CHD) surgery in China. One patient in the group two was transferred to emergency surgery for occluder retrieval and CPB-ASDR. Eight patients experienced failed transthoracic or percutaneous occlusion, two of whom underwent unsuccessful percutaneous closure at another hospital. Two patients each in the groups two and three were intraoperatively converted to CPB-ASDR. Two patient in the group three was converted to transthoracic occlusion surgery. All patients were discharged without any residual shunt. The three-month follow-up also did not show any residual shunt and occluder displacement.ConclusionIn low-weight, infants, or huge ASDs with suitable rim for device occlusion, transthoracic ASD closure was successfully performed. Based on knowledge of ASD anatomy and skilled transthoracic occlusion of ASD, surgeons can perform percutaneous occlusion of ASD under echocardiographic guidance.

Cryptococcal Endocarditis in a Woman with Metastatic Non-Small Cell Lung Cancer: A Case Report and Review of the Literature

Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) have demonstrated improved progression-free survival benefits and decreased treatment-related side effects, and therefore are now considered first-line of treatment of EGFR mutated, metastatic non-small cell lung carcinoma (NSCLC). Cryptococcal endocarditis is an extremely rare clinical entity with only seven reported cases in the literature. Prior cases were seen in patients with a history of rheumatic heart disease or prior valve replacement surgery. Little is known regarding the natural history and optimal management of Cryptococcal endocarditis, given the limited available data. We present a case of Cryptococcal endocarditis and meningitis in a patient with metastatic NSCLC receiving targeted therapy with an EGFR-TKI with no history of significant cardiac disease.

Prolonged length of stay after surgery for adult congenital heart disease: a single-centre study in a developing country.

With the growing number of adults requiring operations for CHD, prolonged length of stay adds an additional burden on healthcare systems, especially in developing countries. This study aimed to identify factors associated with prolonged length of stay in adult patients undergoing operations for CHD. This retrospective study included all adult patients (≥18 years) who underwent cardiac surgery with cardiopulmonary bypass for their CHD from 2011 to 2016 at a tertiary-care private hospital in Pakistan. Prolonged length of stay was defined as hospital stay >75th percentile of the overall cohort (>8 days). This study included 166 patients (53.6% males) with a mean age of 32.05 ± 12.11 years. Comorbid disease was present in 59.0% of patients. Most patients underwent atrial septal defect repair (42.2%). A total of 38 (22.9%) patients had a prolonged length of stay. Post-operative complications occurred in 38.6% of patients. Multivariable analysis showed that pre-operative body mass index (odds ratio: 0.779; 95% confidence interval: 0.620-0.980), intraoperative aortic cross-clamp time (odds ratio: 1.035; 95% confidence interval: 1.009-1.062), and post-operative acute kidney injury (odds ratio: 7.392; 95% confidence interval: 1.036-52.755) were associated with prolonged length of stay. Predictors of prolonged length of stay include lower body mass index, longer aortic cross-clamp time, and development of post-operative acute kidney injury. Shorter operations, improved pre-operative nutritional optimisation, and timely management of post-operative complications could help prevent prolonged length of stay in patients undergoing operations for adult CHD.

Dynamics of parameters of psychological status of patients with stable ischemic heart disease and coronary artery bypass surgery

Aim. Assessment and analysis of parameters of psychological status of patients with coronary heart disease (CHD) referred for coronary artery bypass surgery (CABG).
 Materials and Methods. A study of parameters of psychological status, in particular, of the attitude to illness, coping strategies, and lifelong orientations was conducted in 58 male patients aged 40 to 74 years with a stable form of CHD before and after CABG surgery. The parameters were evaluated by a clinical psychologist in 2-3 days after admission of the patient to the hospital and in 7-8 days after CABG. Clinical and psychological diagnostics was carried out using the following questionnaires: TOBOL (L.I. Wasserman, et al.), Life-Purpose Orientations (D.A. Leontiev), Coping Behavior Strategies (R. Lazarus, adapted version of T.A. Kryukova). Statistical analysis was performed with use of computer Statistica 10.0 software program.
 Results. After CABG patients with coronary artery disease show a significant reduction of the parameters of the anxious variant of the internal picture of the disease on the basis of TOBOL questionnaire, of the positive re-evaluation coping strategy on the basis of evaluation of stress-coping behavior and of the level of Aim scale on the basis of evaluation of the level of neurotization using the Life-Purpose test.
 Conclusion. The results of the study indicate reduction of the level of adaptation to the disease in patients with coronary artery disease after CABG in result of behavioral disorders and difficulties in setting further aims for recovery. To increase postoperative adaptation, the psychocorrection measures may be targeted to the coping strategy for positive re-evaluation and assistance in setting aims in the postoperative stage of CABG.

Implementation of a "threat and error" model in complex neonatal cardiac surgery patients to identify quality improvement opportunities.

Neonates undergoing surgery for congenital heart disease are vulnerable to adverse events. Conventional quality improvement processes centring on mortality and significant morbidity leave a gap in the identification of systematic processes that, though not directly linked to an error, may still contribute to adverse outcomes. Implementation of a multidisciplinary "flight path" process for surgical patients may be used to identify modifiable threats and errors and generate action items, which may lead to quality improvement. A retrospective review of our neonatal "flight path" initiative was performed. Within 72 hours of a cardiac surgery, a meeting of the multidisciplinary patient care team occurs. A "flight path" is generated, graphically illustrating the patient's hospital course. Threats, errors, or unintended consequences are identified. Action items are generated, and a working group is formed to address the items. A patient's flight path is updated weekly until discharge. The errors and action items are logged into a database, which is analysed quarterly to identify trends. Thirty one patients underwent flight path review over a 1-year period; 22.5% (N=7) of patients had an error-free "flight." Eleven action items were generated - four from identified errors and seven from identified threats. Nine action items were completed. Flight path reviews of congenital cardiac patients can be generated with few resources and aid in the detection of quality improvement opportunities. The regular multidisciplinary meetings that occur as a part of the flight path review process can promote inter-professional teamwork.

Preventive effect of low-dose landiolol on postoperative atrial fibrillation study (PELTA study)

ObjectiveTo investigate the efficacy of prophylactic administration of low-dose landiolol on postoperative atrial fibrillation (POAF) in patients after cardiovascular surgery.MethodsConsecutive 150 patients over 70 years of age who underwent cardiovascular surgery for valvular, ischemic heart, and aortic diseases were enrolled in this single-center prospective randomized control study from 2010 to 2014. They were assigned to three treatment groups: 1γ group (landiolol at 1 μg/kg/min), 2γ group (landiolol at 2 μg/kg/min), or control group (no landiolol). In the two landiolol groups, landiolol hydrochloride was intravenously administered for a period of 4 days postoperatively. Electrocardiography was continuously monitored during the study period, and cardiologists eventually assessed whether POAF occurred or not.ResultsPOAF occurred in 24.4% of patients in the control group, 18.2% in 1γ group, and 11.1% in 2γ group (p = 0.256). Multivariate logistic regression analysis showed that the incidence of POAF tended to decrease depending on the dose of landiolol (trend-p = 0.120; 1γ group: OR = 0.786, 95% CI 0.257–2.404; 2γ group: OR = 0.379, 95% CI 0.112–1.287). Subgroup analysis showed a significant dose-dependent reduction in POAF among categories of female sex, non-use of angiotensin II receptor blockers (ARBs) before surgery, and valve surgery (each trend-p = 0.02, 0.03, and 0.004).ConclusionsThese findings indicate that prophylactic administration of low-dose landiolol may not be effective for preventing the occurrence of POAF in overall patients after cardiovascular surgery, but the administration could be beneficial to female patients, patients not using ARBs preoperatively, and those after valvular surgery.

Evaluation of Proportion of Children (0-18 Yrs) Identified and Underwent Surgery for Congenital Heart Diseases Under the Rashtriya Bal Swasthya Karyakram (RBSK), Program in District Thane, Maharashtra State

Evaluation of Proportion of Children (0-18 Yrs) Identified and Underwent Surgery for Congenital Heart Diseases Under the Rashtriya Bal Swasthya Karyakram (RBSK), Program in District Thane, Maharashtra State

Catheter ablation is preferred over surgery for persistent atrial fibrillation.

There are important limitations that can hinder outcomes of surgical ablation in nonparoxysmal patients with atrial fibrillation (AF), which is the typical AF population undergoing concomitant cardiac surgery for valve or ischemic heart disease. Incomplete lesions with recovered conduction or gaps as well as arrhythmias originating from areas not targeted by surgical ablation are commonly seen at the time of recurrence. Therefore, while it might be reasonable to perform AF surgery in this cohort, it is important to know these limitations and establish adequate postoperative rhythm monitoring to detect recurrences, which can be effectively addressed by catheter ablation.

Analysis of risk factors of lower extremity venous thrombosis in pediatric patients after surgery for congenital heart disease

Objective To explore the risk factors of puncture- or catheter-related lower extremity venous thrombosis after surgery for congenital heart disease(CHD). Methods A retrospective analysis was performed on 683 children with venipuncture or venous catheterization in the lower extremities who underwent surgery for CHD in Children′s Heart Center Intensive Care Unit, Henan Provincial People′s Hospital from January 2017 to December 2018, and there were 55 children suspected thrombosis, among whom, 26 cases of thrombosis confirmed by ultrasound were included in the thrombosis group, and 29 cases without thrombosis seen by ultrasound were assigned to the control group.A comparative analysis was carried out to see whether there were statistical differences in the possible risk factors between the 2 groups, and the risk factors of puncture- or catheter-related lower extremity venous thrombosis after operation of CHD. Results The incidence of puncture- or catheter-related lower extremity venous thrombosis after surgery for CHD was 3.81% (26/683 cases). The differences between the thrombosis group and the control group in age (62 d vs.92 d), weight [(3.92±0.66) kg vs.(4.61±0.86) kg], CHD postoperative critical score (Vasoactive-Ventilation-Renal score, VVR)[(29.58±15.50) scores vs.(22.14±11.72) scores], peak blood lactate within 24 hours after surgery [(3.59±0.66) mmol/L vs.(1.71±1.13) mmol/L], postoperative blood transfusion[76.9%(20/26 cases) vs.34.5%(10/29 cases)], co-infection[53.8%(14/26 cases) vs.24.1%(7/29 cases)], cyanotic congenital heart disease [84.6%(22/26 cases) vs.34.5%(10/29 cases)] and puncture difficulty[69.2%(18/26 cases) vs.17.2%(5/29 cases)] were statistically significant(all P<0.05). Logistic regression analysis showed postoperative VVR score (OR=0.88, 95%CI: 0.77-0.99, P=0.04), blood lactate peak within 24 hours after surgery (OR=6.62, 95%CI: 1.35-32.46, P=0.02), and cyanotic congenital heart disease (OR=0.04, 95%CI: 0.00-0.63, P=0.04) were risk factors for venous thrombosis in the lower extremities. Conclusions High postoperative VVR score, high 24 h blood lactate peak after surgery and cyanotic congenital heart disease are high risk factors for puncture- or catheter-related lower extremity venous thrombosis after surgery for CHD. Key words: Congenital heart disease; Lower extremity vein; Thrombosis; Infant

Controlling effects of treprostinil on pulmonary arterial hypertension during surgery for congenital heart disease complicated with severe pulmonary arterial hypertension by echocardiography.

Controlling effects of treprostinil on pulmonary arterial hypertension during surgery for congenital heart disease complicated with severe pulmonary arterial hypertension by echocardiography.

Contemporary Outcomes of Aortic and Mitral Valve Surgery for Rheumatic Heart Disease in Sub-Saharan Africa

Contemporary Outcomes of Aortic and Mitral Valve Surgery for Rheumatic Heart Disease in Sub-Saharan Africa

The effect of dexmedetomidine on the inflammatory response in children undergoing repair of congenital heart disease: a randomized controlled clinical trial

ABSTRACT Background : The inflammatory response due to cardiopulmonary bypass (CBP) activates different inflammatory pathways that affect multiple organs. Dexmedetomidine is proved to affect inflammatory marker production. Objectives: Evaluation of the effect of Dexmedetomidine on the inflammatory response associated with pediatric open-heart surgery using interleukin-6 (IL-6) and interferon-gamma (INF-ɤ) levels. Methods: 61children aged between one to 8 years undergoing elective repair of non-cyanotic congenital heart disease with CPB were randomly assigned into two groups. The control group (31 patients) received normal saline, whereas the Dex group (30 patients) received an initial bolus of Dexmedetomidine 0.5 µg/kg followed immediately by infusion of 0.5 µg/kg/hr continued till the end of CPB. The level of IL-6 and INF-ɤ was measured. Hemodynamic, ICU, and hospital data were recorded. Results: IL-6 and INF -ɤ levels were increased significantly with time in control group, with no increase in their levels in the Dex group. They were significantly lower in the Dex group compared to the control group in samples taken during bypass, 6 h and 24 h after the operation (the end of surgical procedure). There was a significant difference between the groups regarding inotropic score and mechanical ventilation. There was no significant difference between the groups regarding complications, duration of ICU or hospital stay. Conclusion: The use of Dexmedetomidine in pediatric cardiac surgery for non-cyanotic heart disease had significantly attenuated the inflammatory response. It was useful in decreasing the level of inflammatory mediators, inotropic support, and duration of mechanical ventilation, but not the ICU or hospital stay. Trial registration: https://clinicaltrials.gov. (Identifier: NCT03163238).

Pediatric coronary artery surgery. A new area in cardiac surgery?

Introduction and aim: Pediatric coronary artery surgery for congenital heart disease has become increasingly important in newborns and infants. It is life-saving in unsuccessful coronary transfer surgery, injury of coronary artery during surgery, in pediatric coronary artery bypass surgery (PCABS) due to acquired Kawasaki disease. Method: We review the current surgical role of congenital and acquired coronary artery diseases in newborns and infants. Results: The 7 main challenges are: 1) anomalous origin of the left coronary artery from the pulmonary artery; 2) different variations of the origins of the coronary arteries in transposition of the great arteries (TGA); 3) acute and late coronary events in the arterial switch operation for TGA; 4) complications after coronary transfer procedures: Ross-, Nikaidoh operation; 5) inadvertent coronary artery injury during heart surgery; 6) Kawasaki disease; 7) coronary artery procedures in premature infants. Direct coronary reimplantation in most, surgical angioplastic procedures in selected patients is the first choice; however, PCABS with internal thoracic artery (ITA) grafts can be life-saving in emergency or severe myocardial hypoperfusion conditions. Since the patency of saphenous vein grafts is poorer than that of ITA grafts, their use should be avoided in growing children. The procedures can be performed safely in neonates and infants, using high-power magnifying glasses or a surgical microscope. Conclusion: Pediatric coronary artery surgery technique is now established as the standard safety surgical choice, as a new area in cardiac surgery. Congenital heart surgeons after proper training are able to use coronary transfer and bypass surgery safely even in premature babies. Orv Hetil. 2019; 160(49): 1935-1940.

Timing of peptide receptor radiotargeted therapy in relation to cardiac valve surgery for carcinoid heart disease in patients with neuroendocrine metastases and cardiac syndrome: a single centre study from a centre of excellence

Introduction Perioperative mortality of patients who undergo heart valve surgery for carcinoid heart valve disease has been observed to be high (5%-10%). We investigated whether peptide receptor radiotherapy with lutetium-177 dotatate can be used safely in patients with neuroendocrine neoplasm carcinoid heart valve disease and if there is associated survival advantage by reducing overall exposure of the valves to high doses of vasoactive peptides. Method Retrospective case notes review was performed on 18 neuroendocrine neoplasm patients (mean 60 years), who underwent heart valve surgery between 2003 and 2017 for carcinoid heart valve disease, 9 of whom received peptide receptor radiotherapy in addition to surgery. Results All patients were treated with somatostatin receptor antagonists and underwent cardiac valvular surgery (mean two valves replaced) and three benefitted from additional coronary bypass grafting. Nine patients underwent surgery alone: in this group, the time from surgery to progression was 14 months (mean; SD 13.5 months). Nine were treated with peptide receptor radiotherapy in addition to surgery. Six underwent surgery with peptide receptor radiotherapy on progression. Time to progression from surgery to first peptide receptor radiotherapy was mean 25.1 months (SD 23.6 months). No patients developed peritreatment cardiac complications. There were no deaths within the 30-day postoperative period. Average time from surgery to last follow-up/death was 41 months (6-79) in the surgery + lutetium group and in the surgery only group 17 months (1-24). Nine patients died, five in the surgery + lutetium group and four in the surgery only group, all at greater than 1-year postsurgery. Discussion Peptide receptor radiotherapy is safe in the setting of Carcinoid valvular heart disease in patients with controlled heart failure, PPRT can be use in the pre- and post-valve surgery period. There appears to be a survival benefit of having peptide receptor radiotherapy. Further evidence for peptide receptor radiotherapy in the neoadjuvant setting prior to cardiothoracic surgery is required.

P4697Complications and mortality related to non-cardiac surgery in adult congenital heart disease: Results of a nationwide study including 20,450 cases

Abstract Background Adults with congenital heart disease (ACHD) represent a growing patient population with high morbidity and increasing health resource utilization. In addition to acute and chronic cardiac complications, these patients require numerous non-cardiac surgical procedures during their life-time. Limited data on the morbidity and mortality risk related to non-cardiac surgical procedures exist in contemporary CHD patients. The aim of this study was to analyse the frequency and outcome of non-cardiac surgical procedures in contemporary ACHD patients based on all hospital admissions in Germany between 2011 and 2016. Methods Based on the German diagnosis related groups data of patients treated between 2011 and 2016 we identified all ACHD patients treated surgically as inpatients for non-cardiac problems. The dataset contains information on patient demographics, primary and secondary diagnoses, interventional or surgical procedures, duration of stay and outcome including mortality. The primary endpoint of the study was surgery related mortality as well as major adverse events (defined as death or myocardial infarction, stroke, pulmonary embolism, sepsis or resuscitation). Results Overall, 48,872 ACHD cases were hospitalized during the study period. Of these, 20,450 (41.8%) were hospitalized for non-cardiac surgical procedures. The median age at surgery was 50.0 years and 62.9% of patients were male. The overall mortality rate following non-cardiac operations was 2.8% (95% CI 2.6–3.0%). The highest mortality rates were observed for procedure codes involving pharynx, larynx or trachea (27.2%; 95% CI: 22.3–32.1%) and lung surgery (15.4%; 95% CI: 13.3–17.8%). Abdominal surgery (9.2%; 95% CI: 7.7–10.9) and neurosurgical procedures (7.8%; 95% CI: 5.4–10.9) also had relative high mortality rates. The major adverse event rate overall was 12.7% (95% CI 11.7–12.7%). The highest major adverse event rates were observed for surgery of the airways (43.2%; 95% CI: 40.2%-46.4%). Conclusions Non-cardiac surgical procedures are common in ACHD patients and are associated with considerable mortality and morbidity in this cohort. Especially, surgical procedures involving the airways or neurosurgery emerged as risky procedures. However, even for routine abdominal or orthopaedic surgery considerable mortality and morbidity was observed. Overall, our data support careful pre-operative patient evaluation and concentration of surgical procedures at centres with extensive surgical and anaesthetic experience with ACHD patients.

P1889Quantitative global proteomics and lysine acetylome analysis of changes in left atrial appendage tissue from valvular heart disease patients with atrial fibrillation

Abstract Background Previous studies have shown that acetylation plays a critical role in regulating the progress of cardiovascular diseases by acetylated histone and non-histones protein. However, the global lysine acetylome during atrial fibrillation (AF) were not fully understood. Purpose The aim of the present study was to identify the underlying mechanisms of AF via profiling of the quantitative changes of global proteomics and lysine acetylome in the left atrial appendage (LAA) tissues from valvular heart disease patients with AF. Methods This study obtained LAA specimens from patients undergoing cardiac surgery for severe valvular heart disease. The LAA specimens were obtained from both 9 patients with AF and with sinus rhythm (SR). The changes of proteome and acetylome in the AF-LAA vs SR-LAA tissues were studied using dimethyl-labeling, HPLC fractionation, affinity enrichment, LC-MS/MS analysis, database Search and bioinformatic analysis. The acetylated levels of each lysine acetylated site were normalized on the basis of the corresponding protein abundance. Results The bioinformatic analysis indicates 294 up-regulated (AF/SR ratio &gt;1.3) proteins and 169 down-regulated (AF/SR ratio &lt;1/1.3) proteins in the AF-LAA vs SR-LAA were detected. Moreover, 3,880 sites in 1,044 proteins were quantified. Motif analysis of the identified acetylated peptides indicated that a total of 14 significantly enriched amino acid sequence motifs from −10 to +10 surrounding the acetylated lysine (Kac) were defined according to 3412 peptides from 1115 proteins. Among the quantified acetylated sites and proteins, 231 up-regulated acetylated sites in 130 proteins and 121 down-regulated acetylated sites in 74 proteins were detected. The enrichment-based clustering analysis showed that energy metabolism and cardiac contraction-related proteins were highly differentially expressed in the AF-LAA vs SR-LAA. Meanwhile, the protein-protein interaction network of the differentially expressed acetylated proteins demonstrated that there were 146 nodes and 569 interactions in the network and quite a lot of interactions in energy metabolism-related proteins and in cardiac contraction-related proteins. Furthermore, the acetylated levels of most differentially expressed energy metabolism-related proteins involving in oxidative phosphorylation, TCA cycle, respiratory ETC, fatty acid metabolism were up-regulated. On the contrary, the acetylated levels of most acetylated sites in differentially expressed cardiac contraction-related proteins including the key contraction proteins were down-regulated. Interaction network of Ac-proteins Conclusions This study details and expands our understanding of the changes of proteome and lysine acetylome in the LAA tissues from valvular heart disease patients with AF. The data suggest important expression differences of acetylated proteins related to energy metabolism and cardiac contraction which may be involved in the matrix of AF formation and maintainence. Acknowledgement/Funding This work was supported by the grants from the National Natural Science Foundation of China (no. 81600273, no. 81570310, no.81770337 and no.81870258)

P1557Sustainable effectiveness of cardiac rehabilitation in elderly patients in 7 European countries: main results from the EU-CARE study

Abstract Background The EU-CaRE project aims to obtain the evidence base to improve, tailor and optimise cardiac rehabilitation (CR) programmes regarding sustainable effectiveness, cost-effectiveness and participation level in the elderly. Purpose To compare the effect of CR programmes in 7 European countries on the main outcome. Methods The observational EU-CaRE study is a prospective study with eight participating CR sites in seven countries (Denmark, France, Germany, Italy, the Netherlands, Spain and Switzerland). Consecutive patients age 65 or older with coronary heart disease or valve surgery undergoing CR were included. Data were obtained at baseline (T0), at the end of CR (T1) and at 1 year (T2). VO2peak was assessed by cardiopulmonary exercise test. We compared changes in VO2peak across sites in multilevel regression models for repeated measures, adjusting for age, gender, baseline VO2peak, comorbidities, CVD risk factors and educational attainment. Results are reported separately for patients undergoing surgery (CABG/valve replacement) and other indications (MI/stable CAD/PCI). Results 1633 patients were included, and VO2peak was available at all three timepoints for 1243 patients (76%), 492 undergoing surgery and 751 for other indications. Lag time from index event to first CPET and baseline VO2peak varied significantly across centres. Mean age was 72.9 (range 65–90), mean VO2peak at T0 was 16.49 (SD 4.94), at T1, 18.55 (5.33) and at T2 19.03 (5.43) ml/kg/min. For patients not undergoing surgery mean improvement T0-T1 was 1.57 (2.98) and T0-T2 was 1.40 (3.17) ml/kg/min (both p&lt;0.001). In the surgery patients as expected baseline VO2peak was lower but in contrast to non-surgery continued to improve after CR: T0-T1 improvement was 2.77 (2.76) and T0-T2 improvement was 4.29 (3.83) (both p&lt;0.001). At one-year follow-up surgery and non-surgery patients had similar VO2peak (p=0.59). The greatest mean improvement in a site from baseline to one year was 2.04 (3.74) and the smallest 0.59 (2.54) ml/kg/min for non-surgery and, correspondingly 6.13 (4.83) and 1.29 (2.06) ml/kg/min for surgery patients (both multivariable adjusted p for differences between sites p&lt;0.001). In addition to age and gender, baseline and one-year VO2peak was lower in patients with diabetes, hypertension, smokers, patients with other co-morbidity, lower educational attainment and lower mental component score of the SF36. These factors had no systematic impact on the effect of CR. VO2peak at baseline, after CR and 1 year Conclusions The study provides high-quality data on the effectiveness of current CR programmes in Western Europe. Overall, CR was effective in achieving significant improvements in exercise and maintaining these effects. There were significant differences in effect between sites indicating a potential for improvement by adapting CR programs. Acknowledgement/Funding Horizon 2020

P2509Less effect of cardiac rehabilitation for elderly cardiac patients with lower educational attainment

Abstract Background Previous analyses from EU-CaRE study have shown that elderly cardiac patients with basic education have a greater burden of cardiovascular risk factors and a lower exercise capacity at baseline of cardiac rehabilitation (CR). We hypothesize that participation in CR will diminish this socioeconomic gap. Purpose To describe if educational level predicts the benefits of CR in an elderly population in Europe. Methods The observational EU-CaRE study is a prospective study with eight participating CR centers in seven countries (Denmark, France, Germany, the Netherlands, Italy, Spain and Switzerland). Consecutive patients age 65 or older with coronary heart disease or valve surgery participating in CR were included. Data were obtained at baseline (T0) and at the end of CR (T1) and include risk factors for cardiovascular disease, clinical and psychological assessment, medical treatment and exercise capacity. Patients were divided into basic, intermediate and higher educational levels. We compared changes from T0-T1 by multiple regression models. Results A total of 1621 (99% of included) patients were eligible for follow-up analyses. At baseline patients with basic education had more diabetes, higher BMI, lower exercise capacity (VO2 peak) and higher scores for depression (GAD) and anxiety (PHQ-9). At T1 they had improved significantly less on these parameters. The results were not affected by adjustment for gender, age, country and baseline value of the variable. Use of evidence-based medication did not differ by level of education. Difference between T0 and T1 Factor High Intermediate Basic p-value* N total 1621 N=386 N=775 N=460 BMI, mean (SD) −0.16 (0.71) −0.08 (0.82) −0.26 (0.95) 0.794 LDL (mmol/L), mean (SD) −0.07 (0.63) −0.11 (0.62) −0.04 (0.58) 0.978 HbA1c (mmol/mol), mean (SD) 0.23 (3.70) 0.52 (4.39) 0.04 (5.79) 0.021 GAD score, mean (SD) −0.92 (2.72) −0.76 (3.07) −0.13 (3.47) 0.003 PHQ-9 score, mean (SD) −1.45 (3.21) −1.16 (3.36) −0.93 (4.49) &lt;0.001 Diet score, mean (SD) 0.57 (1.72) 0.63 (1.90) 0.23 (1.81) 0.003 VO2 peak (ml/kg/min), mean (SD) 2.47 (2.90) 1.95 (2.78) 1.75 (2.56) 0.016 *Adjusted for gender, age, country and baseline value. Difference in VO2peak, GAD and PHQ score Conclusions In this large European study with high-quality data from 7 CR centers we found an increased gap disfavoring the lower educated elderly patients participating in CR. These results indicate that “one-size cardiac rehabilitation” does not fit all and indicate that a more personalized CR with attention to the different needs of some patient groups is appropriate. Acknowledgement/Funding Horizon2020

Evaluation of an updated sedation protocol to reduce benzodiazepines in a pediatric intensive care unit

Aim: Midazolam like other benzodiazepines is supposed to be neurotoxic in small children and to represent a risk factor for the development of delirium. The aim of this study was to evaluate whether a modified analgesia and sedation protocol is feasible and effective to reduce the requirement of midazolam in neonates and young infants after cardiac surgery.Methods: Patients aged 6 months or younger who underwent surgery for congenital heart disease with cardiopulmonary bypass were enrolled and divided into a pre-modification group (January–December 2016) and after adjusting our sedation protocol into a post-modification group (January–December 2018). We assessed the doses of midazolam, morphine and clonidine as well as sedation scores according to our nurse-driven sedation protocol every 8 h until 120 h after cardiac surgery. During weaning from analgesia and sedation, children were monitored regarding withdrawal symptoms and pediatric delirium.Results: Sixty-five patients were included (33 patients in the pre-modification group, 32 patients in the post-modification group). The number of patients receiving midazolam and the cumulative dose of midazolam could be successfully reduced. The sedation scores were still within the desired target range for adequate sedation without any negative side effects.Conclusions: It is feasible and safe to reduce the use of midazolam in infants after cardiac surgery maintaining sedation goals based on a modified nurse-driven analgesia and sedation protocol.