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Early weight trends after congenital heart surgery and their determinants.
Banerji, N, Sudhakar, A, Balachandran, R, Sunil, GS, Kotayil, BP, Krishna Kumar, R
Cardiology in the young. 2020;(1):89-94
Abstract
BACKGROUND Early weight trends after cardiac surgery in infants from low- and middle-income countries where the majority are undernourished have not been defined. We studied the early post-operative weight trends to identify specific factors associated with early weight loss and poor weight gain after discharge following congenital heart surgery in consecutive infants undergoing cardiac surgery at a referral hospital in Southern India. METHODS This was a prospective observational study. Weights of the babies were recorded at different time points during the hospital stay and at 1-month post-discharge. A comprehensive database of pre-operative, operative, and post-operative variables was created and entered into a multivariate logistic regression analysis model to identify factors associated with excessive early weight loss after cardiac surgery, and poor weight gain following hospital discharge. RESULTS The study enrolled 192 infants (mean age 110.7 ± 99.9 days; weight z scores - 2.5 ± 1.5). There was a small but significant (p < 0.001) decline in weight in the hospital following surgery (1.6% decline (interquartile range -5.3 to +1.7)); however, there was substantial growth following discharge (26.7% increase (interquartile range 15.3-41.8)). The variables associated with post-operative weight loss were cumulative nil-per-oral duration and cardiopulmonary bypass time, while weight gain following discharge was only associated with age. CONCLUSION Weight loss is almost universal early after congenital heart surgery and is associated with complex surgery and cumulative nil-per-oral duration. After discharge, weight gain is almost universal and not associated with any of the perioperative variables.
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Prospective Evaluation of Clinico-Pathological Predictors of Postoperative Atrial Fibrillation: An Ancillary Study From the OPERA Trial.
Corradi, D, Saffitz, JE, Novelli, D, Asimaki, A, Simon, C, Oldoni, E, Masson, S, Meessen, JMTA, Monaco, R, Manuguerra, R, et al
Circulation. Arrhythmia and electrophysiology. 2020;(8):e008382
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Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) occurs in 30% to 50% of patients undergoing cardiac surgery and is associated with increased morbidity and mortality. Prospective identification of structural/molecular changes in atrial myocardium that correlate with myocardial injury and precede and predict risk of POAF may identify new molecular pathways and targets for prevention of this common morbid complication. METHODS Right atrial appendage samples were prospectively collected during cardiac surgery from 239 patients enrolled in the OPERA trial (Omega-3 Fatty Acids for Prevention of Post-Operative Atrial Fibrillation), fixed in 10% buffered formalin, and embedded in paraffin for histology. We assessed general tissue morphology, cardiomyocyte diameters, myocytolysis (perinuclear myofibril loss), accumulation of perinuclear glycogen, interstitial fibrosis, and myocardial gap junction distribution. We also assayed NT-proBNP (N-terminal pro-B-type natriuretic peptide), hs-cTnT, CRP (C-reactive protein), and circulating oxidative stress biomarkers (F2-isoprostanes, F3-isoprostanes, isofurans) in plasma collected before, during, and 48 hours after surgery. POAF was defined as occurrence of postcardiac surgery atrial fibrillation or flutter of at least 30 seconds duration confirmed by rhythm strip or 12-lead ECG. The follow-up period for all arrhythmias was from surgery until hospital discharge or postoperative day 10. RESULTS Thirty-five percent of patients experienced POAF. Compared with the non-POAF group, they were slightly older and more likely to have chronic obstructive pulmonary disease or heart failure. They also had a higher European System for Cardiac Operative Risk Evaluation and more often underwent valve surgery. No differences in left atrial size were observed between patients with POAF and patients without POAF. The extent of atrial interstitial fibrosis, cardiomyocyte myocytolysis, cardiomyocyte diameter, glycogen score or Cx43 distribution at the time of surgery was not significantly associated with incidence of POAF. None of these histopathologic abnormalities were correlated with levels of NT-proBNP, hs-cTnT, CRP, or oxidative stress biomarkers. CONCLUSIONS In sinus rhythm patients undergoing cardiac surgery, histopathologic changes in the right atrial appendage do not predict POAF. They also do not correlate with biomarkers of cardiac function, inflammation, and oxidative stress. Graphic Abstract: A graphic abstract is available for this article.
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Left Atrial Appendage Closure: Prevention and Management of Periprocedural and Postprocedural Complications.
Wilkins, B, Fukutomi, M, De Backer, O, Søndergaard, L
Cardiac electrophysiology clinics. 2020;(1):67-75
Abstract
Left atrial appendage closure (LAAC) is noninferior to oral vitamin K antagonist therapy for the reduction of nonvalvular atrial fibrillation-related stroke risk. Currently, the procedure is most widely accepted in patients who cannot tolerate oral anticoagulants. This patient population is generally comorbid, making any reduction in procedural complications paramount. LAAC has important complications described in the periprocedural and postprocedural periods. The prevention and management of complications regarding vascular access, transseptal puncture, pericardial effusion, device embolization, stroke, air embolusperidevice leak, device-related thrombus and device erosion/ late pericardial effusion are discussed.
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Association of body mass index and all-cause mortality in patients after cardiac surgery: A dose-response meta-analysis.
Liu, X, Xie, L, Zhu, W, Zhou, Y
Nutrition (Burbank, Los Angeles County, Calif.). 2020;:110696
Abstract
Ample studies have reported the effect of body mass index (BMI) on the prognosis of patients undergoing cardiac surgery, but the results remain inconsistent. Therefore, we aimed to conduct a dose-response meta-analysis to clarify the relationship between BMI and all-cause mortality in this population. A systematic search was performed in the PubMed and Embase databases through April 2019 for studies that reported the impact of BMI on all-cause mortality in patients after cardiac surgery. Pooled risk ratios (RRs) were calculated using a random-effects model. Non-linear associations were explored with restricted cubic spline models. Forty-one studies with a total of 54,300 cases/1,774,387 patients were included. The pooled RR for all-cause mortality was 0.93 (95% CI 0.89-0.97) for every 5-unit increment in BMI, indicating that higher BMI did not increase the risk of all-cause mortality in patients after cardiac surgery. A U-shaped association with the nadir of risk at a BMI of 25-27.5 kg/m2 was observed, as well as a higher mortality risk for the underweight and the extremely obese patients. The subgroup analysis revealed that this phenomenon remained regardless of mean age, surgery type, geographic location and number of cases. Overall, for patients after cardiac surgery, a slightly higher BMI may be instrumental in survival, whereas underweight and extreme obesity is associated with a worse prognosis.
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Serum vitamin D status following pediatric cardiac surgery and association with clinical outcome.
Dohain, AM, Almogati, J, Al-Radi, OO, Elassal, AA, Zaher, ZF, Fatani, TH, Abdulgawad, A, Abdelmohsen, G
European journal of pediatrics. 2020;(4):635-643
Abstract
Our aim is to determine the prevalence of vitamin D deficiency in children with congenital heart disease (CHD). In addition, we demonstrated the effect of cardiopulmonary bypass (CPB) on vitamin D, parathyroid hormone (PTH), and calcium levels. The association between perioperative vitamin D levels and postoperative clinical outcomes has been explored. A prospective observational study was conducted from February 2018 to June 2019 on 69 children undergoing elective surgery for CHD under CPB. Blood samples were collected preoperatively, immediate postoperatively, and 24 h postoperatively. Vitamin D deficiency was present in 34 (49.3%) patients preoperatively and 63 (91.3%) patients immediately postoperative. We identified 42.03% decline of 25(OH)D immediately postoperative. Changes in ionized calcium (iCa) concentrations were accompanied by reciprocal alterations in PTH concentrations. Lower postoperative 25(OH)D was associated with higher maximum vasoactive inotropic score (VIS) in the first 24 h postoperative (r = - 0.259, p = 0.03).Conclusion: Vitamin D deficiency is common in children with CHD and the majority are vitamin D deficient following cardiac surgery with acute decline of serum 25(OH)D after CPB. Lower postoperative vitamin D levels in children undergoing cardiac surgery are associated with the need for increasing the inotropic support.What is Known:• Vitamin D is a pleiotropic hormone, important for calcium homeostasis.• Vitamin D deficiency might affect the outcome in critically ill patients.What is New:• Cardiopulmonary bypass causes acute decline of vitamin D in children.• Lower postoperative vitamin D is associated with higher inotropic support.
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Iron deficiency is associated with higher mortality in patients undergoing cardiac surgery: a prospective study.
Rössler, J, Schoenrath, F, Seifert, B, Kaserer, A, Spahn, GH, Falk, V, Spahn, DR
British journal of anaesthesia. 2020;(1):25-34
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BACKGROUND Iron deficiency is frequent in patients undergoing cardiac surgery. The relevance of iron deficiency, however, is ill defined. Therefore, our study aimed to investigate the impact of iron deficiency (ferritin <100 μg L-1) with or without concomitant anaemia on clinical outcome after cardiac surgery. METHODS In this prospective observational study, 730 patients undergoing elective cardiac surgery were assigned into four groups according to their iron status and anaemia. Mortality, serious adverse events (SAEs), major cardiac and cerebrovascular events (MACCEs), allogenic blood transfusion requirements, and length of hospital stay were assessed during a 90-day follow-up period. The effect of iron deficiency on these outcomes was first calculated in models adjusting for anaemia only, followed by two multivariate models adjusting for anaemia and either the EuroSCORE II or any possible confounders. RESULTS The presence of iron deficiency (ferritin <100 μg L-1) was associated with an increase in 90-day mortality from 2% to 5% in patients without anaemia, and from 4% to 14% in patients with anaemia. Logistic regression resulted in an odds ratio of 3.5 (95% confidence interval: 1.5-8.4); P=0.004. The effect persisted in both multivariate models. Moreover, iron deficiency was associated with an increased incidence of SAEs, MACCEs, transfusion, and prolonged hospital stay. CONCLUSIONS Preoperative iron deficiency (ferritin <100 μg L-1) was independently associated with increased mortality, more SAEs, and prolonged hospital stay after cardiac surgery. These findings underline the importance of preoperative iron deficiency screening in the context of a comprehensive patient blood management programme, and highlight its importance as a research topic in cardiac surgery. CLINICAL TRIAL REGISTRATION NCT02031289.
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The influence of postoperative albumin levels on the outcome of cardiac surgery.
Berbel-Franco, D, Lopez-Delgado, JC, Putzu, A, Esteve, F, Torrado, H, Farrero, E, Rodríguez-Castro, D, Carrio, ML, Landoni, G
Journal of cardiothoracic surgery. 2020;(1):78
Abstract
BACKGROUND The prognostic role of low postoperative serum albumin levels (SAL) after cardiac surgery (CS) remains unclear in patients with normal preoperative SAL. Our aim was to evaluate the influence of SAL on the outcome of CS. METHODS Prospective observational study. Patients undergoing CS with normal preoperative SAL and nutritional status were included and classified into different subgroups based on SAL at 24 h after CS. We assessed outcomes (i.e., in-hospital mortality, postoperative complications and long-term survival) and results were analyzed among the different subgroups of SAL. RESULTS We included 2818 patients. Mean age was 64.5 ± 11.6 years and body mass index 28.0 ± 4.3Kg·m- 2. 5.8%(n = 162) of the patients had normal SAL levels(≥35 g·L- 1), 32.8%(n = 924) low deficit (30-34.9 g·L- 1), 44.3%(n = 1249) moderate deficit (25-29.9 g·L- 1), and 17.1%(n = 483) severe deficit(< 25 g·L- 1). Higher SAL after CS was associated with reduced in-hospital (OR:0.84;95% CI:0.80-0.84; P = 0.007) and long-term mortality (HR:0.85;95% CI:0.82-0.87;P < 0.001). Subgroups of patients with lower SAL showed worst long-term survival (5-year mortality:94.3% normal subgroup, 87.4% low, 83.1% moderate and 72.4% severe;P < 0.001). Multivariable analysis showed higher in-hospital mortality, sepsis, hemorrhage related complications, and ICU stay in subgroups of patients with lower SAL. Predictors of moderate and severe hypoalbuminemia were preoperative chronic kidney disease, previous CS, and longer cardiopulmonary bypass time. CONCLUSIONS The presence of postoperative hypoalbuminemia after CS is frequent and the degree of hypoalbuminemia may be associated with worst outcomes, even in the long-term scenario.
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Homozygous Familial Hypercholesterolemia: Anesthetic Challenges and Review of Literature.
Ladha, S, Makhija, N, Kiran, U, Aarav, SK
World journal for pediatric & congenital heart surgery. 2020;(4):NP83-NP87
Abstract
Homozygous familial hypercholesterolemia (HoFH; Fredrickson IIa) is a rare autosomal dominant hereditary disease associated with increased low-density lipoprotein cholesterol. We hereby report anesthetic challenges in a rare case of HoFH having severe progressive aortic stenosis, mitral regurgitation, diffuse aortic and carotid vessel involvement, and severe left ventricular dysfunction. The patient underwent a Konno aortoventriculoplasty with mechanical prosthesis along with mitral valve repair.
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Effect of methylprednisolone on acute kidney injury in patients undergoing cardiac surgery with a cardiopulmonary bypass pump: a randomized controlled trial.
Garg, AX, Chan, MTV, Cuerden, MS, Devereaux, PJ, Abbasi, SH, Hildebrand, A, Lamontagne, F, Lamy, A, Noiseux, N, Parikh, CR, et al
CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2019;(9):E247-E256
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BACKGROUND Perioperative corticosteroid use may reduce acute kidney injury. We sought to test whether methylprednisolone reduces the risk of acute kidney injury after cardiac surgery. METHODS We conducted a prespecified substudy of a randomized controlled trial involving patients undergoing cardiac surgery with cardiopulmonary bypass (2007-2014); patients were recruited from 79 centres in 18 countries. Eligibility criteria included a moderate-to-high risk of perioperative death based on a preoperative score of 6 or greater on the European System for Cardiac Operative Risk Evaluation I. Patients (n = 7286) were randomly assigned (1:1) to receive intravenous methylprednisolone (250 mg at anesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients, caregivers, data collectors and outcome adjudicators were unaware of the assigned intervention. The primary outcome was postoperative acute kidney injury, defined as an increase in the serum creatinine concentration (from the preoperative value) of 0.3 mg/dL or greater (≥ 26.5 μmol/L) or 50% or greater in the 14-day period after surgery, or use of dialysis within 30 days after surgery. RESULTS Acute kidney injury occurred in 1479/3647 patients (40.6%) in the methylprednisolone group and in 1426/3639 patients (39.2%) in the placebo group (adjusted relative risk 1.04, 95% confidence interval 0.96 to 1.11). Results were consistent across several definitions of acute kidney injury and in patients with preoperative chronic kidney disease. INTERPRETATION Intraoperative corticosteroid use did not reduce the risk of acute kidney injury in patients with a moderate-to-high risk of perioperative death who had cardiac surgery with cardiopulmonary bypass. Our results do not support the prophylactic use of steroids during cardiopulmonary bypass surgery. Trial registration: ClinicalTrials.gov, no. NCT00427388.
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A comprehensive program for preterm infants with patent ductus arteriosus.
Apalodimas, L, Waller Iii, BR, Philip, R, Crawford, J, Cunningham, J, Sathanandam, S
Congenital heart disease. 2019;(1):90-94
Abstract
OBJECTIVES Patent ductus arteriosus (PDA) is a common finding in preterm infants. A hemodynamically significant PDA may require intervention for closure. This article aims to describe a transcatheter PDA closure (TCPC) program for preterm infants and the components of a comprehensive outpatient follow-up strategy. SETTING A multidisciplinary team approach including neonatology, cardiology, anesthesiology, medical transport team, pulmonology, cardiac surgery, neurodevelopmental specialist, nutrition, speech therapy, social work, research collaborators, and other health care specialists is integral to the dedicated care and promotion of wellness of extremely low birth weight (ELBW) infants. PATIENTS To date, we have performed TCPC on 134 ELBW infants weighing <2 kg at the time of the procedure, 54 of whom were <1 kg with the smallest weighing 640 g with a median gestation age of 25 weeks (range 23-27 weeks). INTERVENTIONS A comprehensive follow-up strategy with the creation of the Memphis PDA Clinic was implemented. OUTCOME MEASURES Respiratory support, tolerance of enteral feeds, growth, and neurodevelopmental progress are indicators of favorable outcomes. RESULTS TCPC has benefited ELBW infants with faster weaning off the ventilator, increase in enteral feedings, and somatic growth with the overall shortening of the hospital length of stay. The Memphis PDA Clinic has ensured optimal postdischarge follow-up to improve long-term outcomes. CONCLUSIONS TCPC is a safe and effective alternative to manage ELBW infants with a hemodynamically significant PDA. Comprehensive follow-up after discharge provided in a multispecialty clinic developed specifically for this unique population has been successful in improving outcomes.