The Heart Surgery Forum

The Right Ventricle is No Longer the Forgotten Ventricle: Protecting & Managing It

2024-11-24T17:23:17-08:00

No abstract present.

The Impact of Percutaneous Coronary Intervention on Echocardiographic Parameters in Patients with Chronic Total Occlusion of the Coronary Arteries with Diverse Left Ventricular Ejection Fractions: A Single-Center Retrospective Study

2024-12-05T04:52:09-08:00

No abstract present.

Anesthesia Considerations for Transcatheter Tricuspid Valve Repair and Replacement

2024-12-08T21:11:29-08:00

Tricuspid regurgitation is a highly prevalent disease associated with significant morbidity and mortality. Historically, many patients went untreated due to the lack of effective surgical options, high operative risks, and the presence of multiple comorbidities. The emergence of transcatheter valve technologies has transformed this landscape, driving rapid advancements in transcatheter tricuspid valve interventions. Early data indicate promising short- and medium-term outcomes for several devices, though many are still in the early stages of clinical testing. As these interventions become more widely accessible, a thorough understanding of the devices, anesthesia considerations, and potential complications is essential for delivering optimal patient care. This manuscript will present 3 cases of transcatheter tricuspid interventions and review tricuspid valve regurgitation, current techniques for transcatheter tricuspid repair and replacement and the anesthesia considerations for these procedures.

The New Era of Coronary Angioplasty: How Cutting-Edge Technologies are Redefining Complex Interventions

2024-12-09T21:24:51-08:00

Interventional cardiologists have recently become increasingly entrusted with the treatment of frail patients with complex coronary anatomy. Additionally, calcified lesions (CLs) have become more common due to the continued increase in the older population worldwide, increasing the need for simpler treatment options for such complex lesions. Hence, numerous debulking tools have recently been developed to overcome the difficulties associated with the angioplasty of CLs and to optimize stent positioning and delivery. In addition, bifurcation lesions (BLs) have always been more challenging than other lesions, requiring more specialized tools and complex strategies. Finally, intravascular imaging (IVI) is becoming increasingly important in assessing the complexity of lesions and optimizing procedural approaches. This article provides an overview of how complex procedures should be approached, from the choice of access and catheter to the use of specialized devices developed to assist cardiac catheterization laboratory operators in these complex scenarios.

Neurologic Complications Rate Following Aortic Manipulation after Off-Pump Coronary Artery Bypass Grafting: A Meta-Analysis

2024-11-13T16:59:34-08:00

Background: Neurologic complications after coronary artery bypass grafting continue to be among the most devastating complications. The goal of coronary artery bypass grafting, which is performed utilizing off-pump techniques on a beating heart, was to reduce this risk. The purpose of the study was to assess the neurologic complications rate following aortic manipulation after off-pump coronary artery bypass grafting. Methods: Dichotomous random or fixed effect models generated the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) based on the study of the meta-analysis data. 28 papers, with a total of 823,972 patients, were available between 2002 and 2021 and were comprised in this meta-analysis. Results: Aortic manipulation was much less likely to cause a stroke in people with off-pump coronary artery bypass grafting (OR, 0.58; 95% CI, 0.44–0.77; p < 0.001) than non-aortic manipulation. However, no significant difference was found between aortic manipulation and non-aortic manipulation in all-cause mortality (OR, 0.84; 95% CI, 0.69–1.02, p = 0.08), acute renal failure (OR, 0.86; 95% CI, 0.69–1.08, p = 0.20), atrial fibrillation (OR, 0.67; 95% CI, 0.21–2.15, p = 0.50), myocardial infarction (OR, 0.75; 95% CI, 0.56–1.01, p = 0.06), respiratory complications (OR, 0.64; 95% CI, 0.40–1.03, p = 0.07), reoperation for bleeding (OR, 0.89; 95% CI, 0.57–1.38, p = 0.59), and mediastinitis (OR, 0.77; 95% CI, 0.46–1.28, p = 0.31) in subjects with off-pump coronary artery bypass grafting. Conclusions: The present evaluation showed that using aortic manipulation resulted in a significantly lower rate of stroke occurence; however, no significant difference was found in all-cause mortality, acute renal failure, atrial fibrillation, myocardial infarction, respiratory complications, reoperation for bleeding, and mediastinitis compared to non-aortic manipulation in subjects with off-pump coronary artery bypass grafting. However, given that some comparisons comprised a small number of studies, attention ought to be given to their values.

Long-Term Outcomes in Patients Undergoing Thoracic Endovascular Aortic Repair. Single Center Experience

2024-12-15T17:33:05-08:00

Background: To analyze long-term outcomes in patients undergoing thoracic endovascular aortic repair (TEVAR). Methods: All consecutive 97 patients undergoing TEVAR between September 2014 and September 2022 were included in the study. The primary outcome was the long-term incidence of overall death and major adverse cardiovascular and cerebrovascular events (MACCE). Results: Mean age was 70.4 years, and 22 (23.2%) had cerebrovascular disease (CBVD). 49 (51.6%) patients had prior cardiac surgery intervention and 8 (8.5%) had prior aortic valve replacement. Twenty-eight patients (28.8%) presented with aortic dissection, 60 (61.8%) had aortic aneurysm, 4 (4.1%) had intramural hematoma, and 5 (5.1%) had other presentations. An emergent procedure was performed in 6 (6.2%) patients, an urgent procedure in 37 (38.1%) patients and 54 (55.7%) patients had an elective procedure. Intraoperatively, 78.3% had percutaneous TEVAR, 5.1% had ministernotomy TEVAR, while 10.3% had concomitant full sternotomy TEVAR repair. Hospital mortality occurred in 7 patients (7.2%). At 8-year follow-up, 76% were alive, 25.8% had MACCE, 21.6% were diagnosed with endoleaks (13 patients type II and 2 patients type 1) and 10.3% underwent repeat intervention. Conclusions: This single-center study found that patients undergoing TEVAR had good short- and long-term survival and MACCE. Despite almost half of the patients undergoing an urgent/emergent procedure, the clinical outcomes were favorable for TEVAR.

Optimizing Blood Loss Management and Transfusion Strategies in Cardiac Surgery

2024-09-29T18:12:01-07:00

Background: An increase in healthcare costs is the result of the significant hazards to patients associated with excessive blood loss during cardiac surgery and the subsequent need for transfusions. The implementation of effective blood conservation strategies may alleviate these issues. Objectives: This study aimed to assess the correlation between the utilization of anti-fibrinolytic agents and the outcomes of blood loss and transfusion requirements during cardiac interventions, with a particular emphasis on integrated blood conservation strategies. Methods: We conducted a cross-sectional observational study, enrolling 242 patients who underwent elective cardiac surgery, which included valve replacements and coronary artery bypass grafting. The study contrasted the outcomes of patients who received standard surgical care and those who were administered tranexamic acid or aminocaproic acid as part of blood conservation efforts. Results: The results showed a significant reduction in the mean intraoperative blood loss (212.7 vs. 310.4 mL, p < 0.05) and transfusion volume (330.2 vs. 490.1 mL, p < 0.05) in patients who received anti-fibrinolytic agents. Furthermore, these patients experienced shorter hospital stays and lower rates of postoperative complications, such as infections and thrombotic events, in comparison to those who received standard care. Conclusion: The implementation of anti-fibrinolytic agents and other targeted blood conservation strategies may be advantageous in minimizing blood loss and transfusion requirements, which could potentially result in enhanced recovery metrics in cardiac surgery. In order to improve patient outcomes, these strategies should be incorporated into standard surgical protocols.

Prognostic Value of Preoperative Ascending Aortic Diameter on Postoperative Acute Kidney Injury in Adult Cardiac Surgery

2024-12-08T21:16:13-08:00

Background: Ascending aortic diameter (AAD) is commonly measured during ultrasound examinations in cardiac surgery patients and is critical for assessing their prognosis. AAD affects renal perfusion. However, the impact of AAD on the incidence of postoperative acute kidney injury (AKI) in cardiac surgery patients remains unclear. This study aims to explore the prognostic value of AAD for postoperative AKI in adult cardiac patients. Methods: This retrospective study included patients aged ≥18 years who underwent cardiovascular surgeries from April to July 2023 at Fuwai Hospital, China. Patients were categorized into two groups: the AKI group and the non-AKI group. Preoperative cardiac ultrasound values were collected the day before surgery. The primary endpoint was the incidence of AKI. Univariable and multivariable logistic regression analyses were conducted to identify independent risk factors for postoperative AKI. The receiver operating characteristic curve was utilized to evaluate model performance. The effectiveness of including AAD in the model was also assessed. Results: The study comprised 442 patients. Both univariable and multivariable analyses indicated that AAD is an independent predictor of postoperative AKI in both on-pump and off-pump cardiac patients (p < 0.05). To control for the confounding factor of cardiopulmonary bypass (CPB) time, a subgroup analysis was conducted, which showed that including AAD improved the area under the curve (AUC) from 0.67 to 0.72 (p < 0.05) in on-pump patients. Conclusion: AAD is a significant prognostic factor for postoperative AKI in adult cardiac surgery. Its prognostic value is particularly pronounced in on-pump patients. Patients with an enlarged AAD are at a higher risk of developing AKI and experiencing adverse outcomes.

Association between Admission Blood Glucose and In-Hospital MACE in Non-Diabetic STEMI (Killip I) Patients Undergoing Primary PCI

2024-12-16T16:48:37-08:00

Background: The increase in major adverse cardiovascular events (MACE) in patients with diabetes after primary percutaneous coronary intervention (pPCI) is significantly correlated with the admission blood glucose (ABG). However, it is unclear whether ABG in non-diabetic patients is related to MACE after pPCI. We aimed to explore the relationship between ABG and in-hospital MACE in non-diabetic ST-segment elevation myocardial infarction (STEMI) patients with Killip class I treated with pPCI. Methods: The Chinese STEMI pPCI Registry (NCT04996901) enrolled 5586 STEMI patients undergoing pPCI from January 2015 to August 2021. Patients were divided into three groups after excluding those with hyperglycemia (ABG ≥11 mmol/L) and a history of diabetes. MACE was defined by re-infarction, stroke, and cardiovascular death. The association between ABG and in-hospital MACE was assessed using Logistic regression analysis. Results: 2890 non-diabetic STEMI patients with Killip class I treated with pPCI were identified. Patients were divided into three groups based on ABG (Q1: 2.5–5.72 mmol/L; Q2: 5.73–7.0 mmol/L; Q3: 7.01–11.0 mmol/L). After multivariate adjustment for age, gender, Diastolic Blood Pressure (DBP), Heart Rate (HR), smoking, and hypertension, the OR of MACE in Q2 and Q3 were 1.43–1.62 times of Q1 in the calibration Model II to IV. Subgroup analysis showed that the OR of Q2 was 3.52-fold of Q1 in females and 1.54-fold in the elder (≥60 years). Sensitivity analysis showed that after excluding patients with ABG less than 4 mmol/L, elevated ABG was still associated with a significant increase in the risk of MACE. The area under the ROC curve of ABG in predicting the occurrence of MACE after pPCI was 0.668, and the C-index was 0.666. The cubic spline confirmed MACE risk decreased significantly with ABG below 6.3 mmol/L. Conclusions: Elevated ABG is associated with increased risk of in-hospital MACE in non-diabetic STEMI patients treated with pPCI, particularly females and the elderly. This retrospective observational study was registered in Clinical Trials (NCT04996901).

Perioperative Outcomes of Coronary Artery Bypass Grafting in Acute Type A Aortic Dissection

2024-12-08T21:14:07-08:00

Background: This study aimed to evaluate the perioperative outcomes of concomitant coronary artery bypass grafting (CABG) in patients undergoing surgical repair for acute type A aortic dissection (ATAAD) and to assess the impact of CABG on mortality and complications. Methods: A retrospective analysis was conducted on 1198 ATAAD patients who underwent surgical treatment at our center between January 2016 and December 2022. Patients were categorized into CABG and non-CABG groups. Preoperative characteristics, surgical data, and perioperative outcomes were collected and analyzed. Results: A total of 1198 patients underwent surgical treatment in this study, of whom 979 (81.7%) were male. The mean age was 51.7 ± 11.5 years. Among these patients, 91 (7.6%) underwent concomitant CABG. Patients in the CABG group had significantly higher incidences of chronic coronary artery disease (58.2% vs. 22.6%, p < 0.001), acute myocardial infarction (59.3% vs. 9.5%, p < 0.001), and neurological events (28.6% vs. 18.2%, p = 0.016) compared to the non-CABG group before surgery. Among all patients who underwent surgical treatment, 96 (8.0%) experienced perioperative death. The perioperative mortality rate was significantly higher in the CABG group (39.6% vs. 5.4%, p < 0.001). Patients in the CABG group also had higher rates of postoperative complications, including heart failure, neurological events, continuous renal replacement therapy (CRRT), re-exploration for bleeding, multiple organ dysfunction syndrome (MODS), and need for extracorporeal membrane oxygenation (ECMO) support (all p-values < 0.001). Compared to patients without concomitant CABG, those undergoing CABG had a much higher rate of mortality (Odds Ratio = 2.729, 95% CI = 1.282–5.812, p = 0.009). Conclusions: Concomitant CABG in ATAAD patients was significantly associated with higher perioperative mortality and complication rates.

Efficacy and Feasibility of Preoperative Autologous Blood Donation in Elective On-pump Cardiac Surgeries: A Propensity-score Matching Study

2024-11-26T16:43:24-08:00

Objective: The global shortage of blood resources has become a significant concern. This study aimed to assess the effects and feasibility of preoperative autologous blood donation (PABD) in elective on-pump cardiac surgeries. Methods: This retrospective single-center study included 219 patients who underwent elective on-pump cardiac surgeries between January 2015 and June 2023. All procedures were performed by a single experienced surgical team. Of these patients, 101 (PABD group) donated autologous blood preoperatively and were compared with the Non-PABD group (n = 118). Using the propensity-score matching (PSM) method, 83 well-matched pairs were yielded based on five variables: gender, age, baseline hemogloin level, left ventricular ejection fraction (LVEF), and EuroscoreII. Transfusion data and perioperative outcomes were retrospectively compared. Multivariate logistic regression analyses were employed to assess the independent impact of PABD on outcome indicators. Results: In the propensity-matched cohort, there were significant reductions in allogenic red blood cell (RBC) transfusion in the PABD group, both intraoperatively and postoperatively (p < 0.05). Patients in the PABD group experienced a shorter duration of mechanical ventilation (p < 0.05). There was no significant difference in early mortality (p = 0.613). However, the incidences of hemoglobinuria and acute kidney injury (AKI) were significantly lower in the PABD group (p = 0.016 and p = 0.043, respectively). Furthermore, the use of PABD was identified as an independent protective factor for postoperative AKI odds ratio (OR = 0.204; 95% CI, 0.051–0.816; p = 0.025) and hemoglobinuria (OR = 0.141; 95% CI, 0.027–0.723; p = 0.019). Conclusion: The use of PABD in cardiac surgeries is beneficial, reducing allogenic RBC transfusions and certain complications without increasing adverse events.

Emergency and Salvage Coronary Artery Bypass Grafting: Surgical Techniques, Outcomes, and Predictors of In-Hospital Mortality

2024-11-11T00:21:00-08:00

Background: Emergency and salvage coronary artery bypass grafting (CABG) is a high-risk procedure often performed on critically ill patients where percutaneous coronary intervention is unsuitable or has been unsuccessful. Despite advancements in surgical techniques, the optimal approach between on-pump CABG (ONCAB) and off-pump CABG (OPCAB) in these settings remains debated, particularly concerning their impact on in-hospital mortality and long-term outcomes. This study aimed to compare the effects of ONCAB and OPCAB on in-hospital outcomes and long-term survival of patients undergoing emergency and salvage CABG and determine the predictors of in-hospital mortality for this high-risk cohort of patients. Method: A retrospective analysis was conducted on data from 459 patients who underwent emergency or salvage CABG between January 1996 and September 2023. Of these, 246 underwent ONCAB, and 213 underwent OPCAB. Propensity score matching (PSM) was applied to create a balanced cohort of 181 patients in each group, adjusting for preoperative characteristics. Univariate and multivariate logistic regression analyses were performed to identify predictors of in-hospital mortality, and Kaplan–Meier survival curves were generated to assess long-term survival. Results: In the matched cohort, in-hospital mortality was 11.6% for ONCAB and 6.6% for OPCAB (p = 0.100). Independent predictors of in-hospital mortality included advanced age (p = 0.042), high New York Heart Association classification (p = 0.002), diabetes (p = 0.042), and salvage procedures (p < 0.001). OPCAB was not independently associated with in-hospital mortality (p = 0.189). Long-term survival at 20 years was similar between ONCAB and OPCAB (p = 0.6263). Conclusions: Despite a relatively high in-hospital mortality, emergency and salvage CABG patients have acceptable short-term outcomes and long-term survival. The choice of surgical strategy does not impact outcomes. Emergency and salvage CABG remains viable and should be offered to suitable candidates.

Impact of Nurse Practitioners on Guideline-Directed Medical Therapy at Discharge on Patients with Recent Acute Coronary Syndrome after Coronary Artery Bypass Graft Surgery

2024-11-13T17:02:11-08:00

Background: Skills and knowledge of acute care nurse practitioners (ACNPs) are important resources within the healthcare team. Few studies have been conducted on their impact in terms of adherence to guideline-directed medical therapy (GDMT) at the time of discharge. Methods: A retrospective cohort study of 160 patients with a diagnosis of recent acute coronary syndrome (ACS) prior to coronary artery bypass graft surgery in Eastern Canada was conducted. Eighty randomly selected patients in each group were compared, one led by the physicians, and the other with the presence of ACNPs within the team. Results: In the physician-led group, adherence to GDMT at discharge was not reached in 47 patients versus six in the group with ACNPs (58.8% vs. 7.5%; χ² (1) = 45.58; p = 0.0001). Of the 47 non-adherent patients, 29 suffered a nonST segment elevation myocardial infarction. The main reason for non-adherence in both groups was the omission of dual antiplatelet therapy prescription. Mean length of stay in hours was longer in the physician-led group than in the group with ACNPs (148.1 vs. 127; F (1, 158) = 2.053; p = 0.154). At 30 days, returns to the emergency department (9 vs. 16; χ² (1) = 2.323, p = 0.127) and readmissions (4 vs. 8; χ² (1) = 1.441, p = 0.230) for cardiac surgery complications were not statistically different between both groups. Conclusion: On a cardiac surgery unit, the ACNP is a valuable addition with respect to adherence to GDMT at discharge in an ACS population post surgical revascularization.

The Angiotensin Receptor–Neprilysin Inhibitor is Related to Lower Post-transplant Use of Extracorporeal Membrane Oxygenation

2024-11-04T17:04:06-08:00

Background: Extracorporeal membrane oxygenation (ECMO) support after heart transplant is a risk factor for mortality in patients with severe graft dysfunction. Extensive studies have shown that angiotensin receptor–neprilysin inhibitor (ARNI) sacubitril–valsartan has a significant effect on unloading and vascular remodeling in patients with heart failure; however, the impact of ARNIs on heart transplant recipients remains unknown. Methods: This observational, retrospective cohort study included 152 patients who underwent heart transplantation between January 2015 and April 2021. We excluded patients <18 years old and those who underwent re-transplantation or multiple organ transplantation. Patients were divided into two groups based on whether they received an ARNI for at least one month before transplant. The clinical data of recipients and donors from our institutional medical records and the China Organ Transplant Response System were interrogated. Results: In total, 67 patients (mean age, 49.6 years; 81% male) were treated with sacubitril/valsartan before transplant and included in the cohort. The total rate of post-transplant ECMO use was 21.1% (n = 32). Kaplan–Meier survival analysis showed a considerable increase in 6-month mortality in heart transplant recipients supported by ECMO (log-rank p < 0.001). The rate of ECMO use was significantly lower in patients treated with ARNIs than for those who were not (13% vs. 27%; p = 0.041). The multivariate analyses that included three models with different preset covariates demonstrated a lower risk of post-transplant ECMO support in patients receiving the ARNI (all p < 0.05). After propensity score matching, the results also suggested that ARNIs can be a protective factor against post-transplant ECMO support (p = 0.042). Conclusion: Pretransplant use of ARNI agents was associated with a lower risk of ECMO support after HT. Randomized controlled trials are warranted to confirm the effectiveness of ARNIs in improving post-transplant hemodynamics and reducing ECMO use in HT recipients.

Time-Driven Activity-Based Costing Analysis of Coronary Flow Velocity Reserve Assessment with Regadenoson Stress Echocardiography

2024-12-17T16:39:51-08:00

Objective: Accurate measurement of healthcare costs is required to assess and improve the value of Regadenoson stress echocardiography (RSE). The purpose of this study was to determine the costs associated with Regadenoson stress echocardiography. Methods: Time-Driven Activity-Based Costing (TDABC) was used to calculate the non-directly traceable cost of RSE. Data were collected between January 2021 and December 2023. TDABC steps involved (1) constructing process maps for the RSE pathway; (2) determining capacity cost rates for staff, medical equipment, space, water and electricity; (3) measuring the time required for each process through direct observation and participation and (4) calculating the total non-directly traceable cost of RSE. Finally, the total costs of RSE were obtained by summing up the direct retroactive cost and non-directly traceable cost. Results: Total costs of RSE were 1306.18 Chinese Yuan ($181.60), of which Regadenoson, human resources and equipment accounted for 61.09%, 19.96% and 13.17%, respectively. Conclusion: Regadenoson expense was the greatest contributor to the costs of RSE, followed by labor cost. Understanding the actual costs and cost drivers of RSE may better inform resource utilization to lower the cost and improve the quality of RSE.