CONTEXT Perioperative red blood cell transfusion is commonly used to address anemia, an independent risk factor for morbidity and mortality after cardiac operations; however, evidence regarding ...optimal blood transfusion practice in patients undergoing cardiac surgery is lacking. OBJECTIVE To define whether a restrictive perioperative red blood cell transfusion strategy is as safe as a liberal strategy in patients undergoing elective cardiac surgery. DESIGN, SETTING, AND PATIENTS The Transfusion Requirements After Cardiac Surgery (TRACS) study, a prospective, randomized, controlled clinical noninferiority trial conducted between February 2009 and February 2010 in an intensive care unit at a university hospital cardiac surgery referral center in Brazil. Consecutive adult patients (n = 502) who underwent cardiac surgery with cardiopulmonary bypass were eligible; analysis was by intention-to-treat. INTERVENTION Patients were randomly assigned to a liberal strategy of blood transfusion (to maintain a hematocrit ≥30%) or to a restrictive strategy (hematocrit ≥24%). MAIN OUTCOME MEASURE Composite end point of 30-day all-cause mortality and severe morbidity (cardiogenic shock, acute respiratory distress syndrome, or acute renal injury requiring dialysis or hemofiltration) occurring during the hospital stay. The noninferiority margin was predefined at −8% (ie, 8% minimal clinically important increase in occurrence of the composite end point). RESULTS Hemoglobin concentrations were maintained at a mean of 10.5 g/dL (95% confidence interval CI, 10.4-10.6) in the liberal-strategy group and 9.1 g/dL (95% CI, 9.0-9.2) in the restrictive-strategy group (P < .001). A total of 198 of 253 patients (78%) in the liberal-strategy group and 118 of 249 (47%) in the restrictive-strategy group received a blood transfusion (P < .001). Occurrence of the primary end point was similar between groups (10% liberal vs 11% restrictive; between-group difference, 1% 95% CI, −6% to 4%; P = .85). Independent of transfusion strategy, the number of transfused red blood cell units was an independent risk factor for clinical complications or death at 30 days (hazard ratio for each additional unit transfused, 1.2 95% CI, 1.1-1.4; P = .002). CONCLUSION Among patients undergoing cardiac surgery, the use of a restrictive perioperative transfusion strategy compared with a more liberal strategy resulted in noninferior rates of the combined outcome of 30-day all-cause mortality and severe morbidity. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01021631
To analyze the impact of vacuum-assisted venous drainage (VAVD) on arterial pump flow in a simulated pediatric cardiopulmonary bypass circuit utilizing a centrifugal pump (CP) with an external ...arterial filter.
The simulation circuit consisted of a Quadrox-I Pediatric oxygenator, a Rotaflow CP (Maquet Cardiopulmonary AG, Rastatt, Germany), and a custom pediatric tubing set primed with Lactated Ringer's solution and packed red blood cells. Venous line pressure, reservoir pressure, and arterial flow were measured with VAVD turned off to record baseline values. Four other conditions were tested with progressively higher vacuum pressures (-20, -40, -60, and -80 mmHg) applied to the baseline cardiotomy pressure. An arterial filter was placed into the circuit and arterial flow was measured with the purge line in both open and closed positions. These trials were repeated at set arterial flow rates of 1500, 2000, and 2500 mL/min.
The use of progressively higher vacuum caused a reduction in effective arterial flow from 1490±0.00 to 590±0.00, from 2020±0.01 to 1220±0.00, and from 2490±0.0 to 1830±0.01 mL/min. Effective forward flow decreased with increased levels of VAVD.
The use of VAVD reduces arterial flow when a CP is used as the main arterial pump. The reduction in the forward arterial flow increases as the vacuum level increases. The loss of forward flow is further reduced when the arterial filter purge line is kept in the recommended open position.An independent flow probe is essential to monitor pump flow during cardiopulmonary bypass.
Anemia in Cardiac Surgery - Can Something Bad Get Worse? Faria, Leandro Batisti de; Mejia, Omar Vilca; Miana, Leonardo Augusto ...
Brazilian Journal of Cardiovascular Surgery,
01/2021, Letnik:
36, Številka:
2
Journal Article
Odprti dostop
Anemia and blood transfusion are risk factors for morbidity/mortality in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). The objective of this study is to analyze the ...association of blood transfusion with morbidity/ mortality in patients undergoing coronary artery bypass grafting (CABG) under CPB in the state of São Paulo, Brazil.
This is a retrospective analysis using the State of São Paulo Registry of Cardiovascular Surgery from November 2013 to August 2014. Blood transfusion was only considered during surgery or within six hours after surgery. Anemia was defined as hematocrit ≤ 37.5%. Patients < 18 years old were excluded. The sample was divided in four groups - Group I (851, no anemia), Group II (200, anemia without blood transfusion), Group III (181, no anemia and transfusion), and Group IV (258, anemia and transfusion).
A total of 1,490 patients were included; 639 (42.9%) were anemic and 439 (29.5%) underwent blood transfusion. Group II showed lower composite morbidity (odds ratio OR -0.05; confidence interval CI -0.27-0.17; P=0.81) than Group III (OR 0.41; CI 0.23-0.59; P=0.018) or Group IV (OR 0.54; CI 0.31- 0.77; P=0.016). Group III was at greater risk of mortality (OR 0.73; CI 0.43-1.03; P=0.02) than Group II, which was exposed only to anemia (OR -0.13; CI -0.55-0.29; P=0.75), or Group IV (OR 0.29; CI -0.13-0.71; P=0.539).
Anemia in patients undergoing CABG with CPB is bad, but blood transfusion can be worse, increasing at least 50% the risk for mortality and/or morbidity.
This study aimed to evaluate Ebstein's anomaly surgical correction and its early and long-term outcomes.
A retrospective analysis of 62 consecutive patients who underwent surgical repair of Ebstein's ...anomaly in our institution from January 2000 to July 2016. The following long-term outcomes were evaluated: survival, reoperations, tricuspid regurgitation, and postoperative right ventricular dysfunction.
Valve repair was performed in 46 (74.2%) patients - 12 of them using the Da Silva cone reconstruction; tricuspid valve replacement was performed in 11 (17.7%) patients; univentricular palliation in one (1.6%) patient; and the one and a half ventricle repair in four (6.5%) patients. The patients' mean age at the time of surgery was 20.5±14.9 years, and 46.8% of them were male. The mean follow-up time was 8.8±6 years. The 30-day mortality rate was 8.06% and the one and 10-year survival rates were 91.9% both. Eleven (17.7%) of the 62 patients required late reoperation due to tricuspid regurgitation, in an average time of 7.1±4.9 years after the first procedure.
In our experience, the long-term results of the surgical treatment of Ebstein's anomaly demonstrate an acceptable survival rate and a low incidence of reinterventions.
Deep sternal wound infections (DSWI) are so serious and costly that hospital services continue to strive to control and prevent these outcomes. Microcosting is the more accurate approach in economic ...healthcare evaluation, but there are no studies in this field applying this method to compare DSWI after isolated coronary artery bypass grafting (CABG). This study aims to evaluate the incremental risk-adjusted costs of DSWI on isolated CABG.
This is a retrospective, single-center observational cohort study with a propensity score matching for infected and non-infected patients to compare incremental risk-adjusted costs between groups. Data to homogeneity sample was obtained from a multicentric database, REPLICCAR II, and additional sources of information about costs were achieved with the electronic hospital system (Si3). Inflation variation and dollar quotation in the study period were corrected using the General Market Price Index. Groups were compared using analysis of variance, and multiple linear regression was performed to evaluate the cost drivers related to the event.
As expected, infections were costly; deep infection increased the costs by 152% and mediastinitis by 188%. Groups differed among hospital stay, exams, medications, and multidisciplinary labor, and hospital stay costs were the most critical cost driver.
In summary, our results demonstrate the incremental costs of a detailed microcosting evaluation of infections on CABG patients in São Paulo, Brazil. Hospital stay was an important cost driver identified, demonstrating the importance of evaluating patients' characteristics and managing risks for a faster, safer, and more effective discharge.
Background
Anomalous aortic origin of coronary artery is a rare finding, with varied presentation and symptomatology. Increasingly recognized by cardiac imaging, when found it raises questions about ...the appropriate approach and management.
Case presentation
We present a case of an 11‐year‐old female who presented with episodes of shortness of breath, angina, and syncope during exercise. Further investigation demonstrated episodes of nonsustained ventricular tachycardia on Holter and coronary angiotomography revealed that the left coronary artery had an anomalous origin from the right cusp with initial short intramural segment and significant external compression in its initial course between the aorta and the pulmonary artery. The patient was submitted to surgical correction with dissection of left coronary artery posterior to the pulmonary artery, coronary arteriotomy, roof ampliation with the autologous pericardium, and creation of neo‐ostium in aorta. The patient had a satisfactory postoperative recovery, was discharged on the fifth‐day post‐op, and remains asymptomatic after 14 months of follow‐up. Herein we present surgical video and postoperative echo and computed tomography scan.
Introduction: The coronavirus disease 2019 (COVID-19) has negatively impacted healthcare services worldwide. We hypothesized that the pandemic would affect our case mix and mortality. Our objective ...was to study this impact. Methods: We retrospectively studied all patients who underwent congenital heart surgeries from March 21st to August 21st in 2019 and 2020 using the institutional electronic database. We compared demographic data, preoperative and postoperative length of stay (LOS), risk stratification using Risk Adjustment for Congenital Heart Surgery (RACHS) classification and outcomes in both periods. Results: We observed a 66.7% decrease in our surgical volume (285 × 95 patients). Patients operated in the pre-pandemic period were older (911.3 174.8 - 5953.8 days-old) compared to the pandemic period (275 days-old; P<0.05). When the case mix was compared between periods, the percentage of neonatal surgery was increased in the pandemic era (8% × 21.1%; P<0.05), and the number of RACHS 1-2 surgeries decreased significantly (60.7 × 27.4%; P<0.05). Preoperative LOS was increased in the pandemic period (1.2 × 7 days; P=0.001). There was no significant increment in mortality (P=0.1). Two patients tested positive for COVID-19 in the postoperative period and both died. Conclusion: Our program observed a sudden decrease in surgical volume and a consequent increase in surgical complexity. There was a non-significant increment in mortality.
Objectives
This article aimed to compare the outcomes after hybrid revascularization with conventional coronary artery bypass grafting (CABG) surgery.
Background
The concept of hybrid coronary ...revascularization combines the advantages of CABG and percutaneous coronary intervention to improve the treatment of patients with complex multivessel disease.
Methods
The Myocardial hybrid revascularization versus coronary artERy bypass GraftING for complex triple‐vessel disease—MERGING study is a pilot randomized trial that allocated 60 patients with complex triple‐vessel disease to treatment with hybrid revascularization or conventional CABG (2:1 ratio). The primary outcome was the composite of all‐cause death, myocardial infarction, stroke, or unplanned repeat revascularization at 2 years.
Results
Clinical and anatomical characteristics were similar between groups. After a mean follow‐up of 802 ± 500 days, the primary endpoint rate was 19.3% in the hybrid arm and 5.9% in the CABG arm (p = NS). The incidence of unplanned revascularization increased over time in both groups, reaching 14.5 versus 5.9% in the hybrid and in the CABG groups, respectively (p = .4). Of note, in the hybrid group, there were no reinterventions driven by the occurrence of stent restenosis.
Conclusions
Hybrid myocardial was feasible but associated with increasing rates of major adverse cardiovascular events during 2 years of clinical follow‐up, while the control group treated with conventional surgery presented with low rates of complications during the same period. In conclusion, before more definitive data arise, hybrid revascularization should be applied with careful attention in practice, following a selective case‐by‐case indication.
Elevated neutrophil-lymphocyte ratio (NLR) has been associated with poorer outcomes in cyanotic patients undergoing single ventricle palliation. Little is known about this biomarker on patients with ...tetralogy of Fallot (TOF), the most common cyanotic congenital heart disease. Our objective is to study the impact of preoperative NLR on outcomes of TOF patients undergoing total repair.
This retrospective study included 116 consecutive patients between January 2014 and December 2018. Preoperative NLR was measured from the last complete blood count test before the surgery. Using the cutoff value of 0.80, according to the receiver-operating characteristic (ROC) curve, the sample was divided into two groups (NLR < 0.80 and ≥ 0.80). The primary endpoint was hospital length of stay (LOS).
ROC curves showed that higher preoperative NLR was associated with longer hospital LOS, with an area under the curve of 0.801±0.040 (95% confidence interval 0.722 - 0.879; P<0.001). High preoperative NLR was also associated with long intensive care unit (ICU) LOS (P=0.035). Preoperative NLR predicted longer hospital LOS with a sensitivity of 63% and a specificity of 81.4%.
Higher preoperative NLR was associated with long ICU and hospital LOS in patients undergoing TOF repair.
The objective of this study was to compare the hemodynamic performances and gaseous microemboli (GME) handling ability of two pediatric oxygenators in a simulated pediatric cardiopulmonary bypass ...(CPB) model and the importance of adding an arterial filter in the circuit. The circuit consisted of a Braile Infant oxygenator or a Maquet Quadrox‐I Pediatric oxygenator without integrated arterial filter (parallel arrangement), 1/4 in. ID tubing A‐V loop, and a 12‐Fr arterial cannula, primed with lactated Ringer's solution and packed red blood cells. Trials were conducted at flow rates ranging from 500 to 2000 mL/min (500 mL/min increment) at 35°C and 28°C. Real‐time pressure and flow data were recorded using a custom‐based data acquisition system. For GME testing, 5 cc of air was manually injected into the venous line. GME were recorded using the Emboli Detection and Classification Quantifier (EDAC) System. An additional experiment using a separate arterial filter was conducted. There was no difference in the mean circuit pressure, pressure drop, total hemodynamic energy level, and energy loss between the two oxygenators. The venous line pressures were higher in the Braile than in the Quadrox group during all trials (P <0.01). GME count and volume at pre‐/post oxygenator and pre‐cannula sites in the Quadrox were lower than the Braile group at high flow rates (P < 0.05). In the additional experiment, an arterial filter captured a significant number of microemboli at all flow rates. The Braile Infant oxygenator has a matched hemodynamic characteristic with the Quadrox‐i Pediatric oxygenator. The Quadrox‐i has a better GME handling ability compared with the Braile Infant oxygenator. Regardless of type of oxygenator an additional arterial filter decreases the number of GME.
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