Delirium is a common complication after cardiac surgical procedures and is associated with increased morbidity and mortality. However, whether rigorously assessed postoperative delirium is associated ...with an increased length of stay in the intensive care unit (LOS-ICU), length of stay (LOS), and hospital charges is not clear.
Patients (n = 66) undergoing coronary artery bypass or valve operations, or both, were enrolled in a nested cohort study. Rigorous delirium assessments were conducted using the Confusion Assessment Method. LOS-ICU and LOS were obtained from the medical record, and hospital charges were obtained from administrative data reported to the state. Because of the skewed distribution of outcome variables, outcomes were compared using rank-sum tests, as well as median regression incorporating propensity scores.
Patients who developed delirium (56%) versus no delirium (43%) had increased median LOS-ICU (75.6 hours interquartile range (IQR): 43.6 to 136.8 vs. 29.7 hours IQR: 21.7 to 46.0; p = 0.002), increased median LOS (9 days IQR: 6 to 16 vs. 7 days IQR: 5 to 8; p = 0.006), and increased median hospital charges ($51,805 IQR: $44,041 to $80,238 vs. $41,576 IQR: $35,748 to $43,660; p = 0.002). In propensity score models adjusted for patient-related and surgical characteristics and complications, the results for LOS-ICU and cost remained highly significant, although the results for LOS were attenuated on the basis of the specific statistical model. Increased severity of delirium was associated with both increased LOS-ICU and increased charges in a dose-response manner.
Delirium after cardiac surgical procedures is independently associated with both increased LOS-ICU and higher hospital charges. Because delirium is potentially preventable, targeted delirium-prevention protocols for high-risk patients may represent an important strategy for quality improvement.
Ghosts in the machines Shah, Ashish S.
The Journal of thoracic and cardiovascular surgery,
July 2018, 2018-07-00, 20180701, Letnik:
156, Številka:
1
Journal Article
Background and Aims The role of endoscopic submucosal dissection (ESD) in Barrett’s early neoplasia is not well defined, with most studies originating from Asia and Europe. We aimed to assess the ...efficacy, safety, and results of ESD in Barrett’s esophagus (BE) with high-grade dysplasia (HGD) and early adenocarcinoma (EAC) across centers in the United States. Methods Multicenter retrospective analysis on 46 patients with BE who underwent ESD for BE-HGD or EAC, or both, between January 2010 and April 2015. The primary endpoint was the rate of en bloc resection. Secondary aims included rate of R0 (complete) and curative resection, a comparison of pre- and post-ESD histology, procedure-related adverse events, and rate of remission at follow-up. Results Median age was 69 years (range, 42-82 years). The median resected specimen size was 45 mm (range, 13-125 mm). En bloc and curative resection rates were 96% (44/46) and 70% (32/46), respectively. Most lesions (11/20; 55%) diagnosed as BE-HGD on biopsy were upstaged to intramucosal or invasive EAC on post-ESD histopathology. There were 4 early (<48 hours) adverse events (3 bleeding and 1 perforation), and all were treated endoscopically. Seven patients (15%) developed esophageal strictures that were managed endoscopically. Complete remission of BE neoplasia was found in 100% (32/32) of patients with curative resection at median follow-up of 11 months (range, 2-25 months). Conclusions This is the largest multicenter series of ESD for early neoplastic BE from the United States. ESD appears to be safe and effective, with high en bloc and curative resection rates in the treatment of early BE neoplasia.
Given the shortage of suitable donor hearts for cardiac transplantation and the growing interest in donation after circulatory death (DCD), our institution recently began procuring cardiac allografts ...from DCD donors.
Between October 2020 and March 2021, 15 patients with heart failure underwent cardiac transplantation using DCD allografts. Allografts were procured using a modified extracorporeal membrane oxygenation circuit for thoracic normothermic regional perfusion (TA-NRP) and were subsequently transported using cold static storage. Data collection and analysis were performed with institutional review board approval.
The mean age of the DCD donors was 23 ± 7 years and average time on TA-NRP was 56 ± 8 minutes. Total ischemic time was 183 ± 31 minutes and distance from transplant center was 373 ± 203 nautical miles. Recipient age was 55 ± 14 years, with 8 (55.3%) recipients on durable left ventricular assist device support. Post-transplant, 6 (40%) recipients experienced mild left ventricle primary graft dysfunction (PGD-LV), 3 (20%) recipients experienced moderate PGD-LV, and no recipients experienced severe PGD-LV. Postoperative transthoracic echocardiogram demonstrated left ventricular ejection fraction >55% in all recipients. One recipient (6.6%) developed International Society for Heart and Lung Transplantation 2R acute cellular rejection on first biopsy. At last follow-up, all 15 recipients were alive past 30-days.
Cardiac DCD provides an opportunity to increase the availability of donor hearts for transplantation. Utilizing TA-NRP with cold static storage, we have extended the cold ischemic time of DCD allografts to almost 3 hours, allowing for inter-hospital organ transport.
Time to read the fine print Shah, Ashish S.
The Journal of thoracic and cardiovascular surgery,
January 2018, 2018-01-00, 20180101, Letnik:
155, Številka:
1
Journal Article
It is not just the driveline Shah, Ashish S.
The Journal of thoracic and cardiovascular surgery,
January 2018, 2018-01-00, 20180101, Letnik:
155, Številka:
1
Journal Article
Structured abstract Background We sought to determine whether a pilot goal-directed perfusion initiative (GDP) could reduce the incidence of acute kidney injury (AKI) following cardiac surgery. ...Methods Based on available literature, we identified goals to achieve during cardiopulmonary bypass (including maintenance of oxygen delivery>300 mL O2/min/m2 , and reduction in vasopressor use) which were combined into GDP and implemented as a quality improvement measure in cardiac surgery patients at our institution during 2015. GDP patients were matched to controls who underwent cardiac surgery between 2010-2015 using propensity scoring across 15 variables. The primary and secondary outcomes were the incidence of AKI and the mean rise in serum creatinine within the first 72 hours following cardiac surgery. Results We utilized GDP in 88 patients, and matched these to 88 control patients who were similar across all variables including mean age (61 years in controls vs. 64 in GDP patients, p=0.12) and preoperative glomerular filtration rate (90 vs. 83, p=0.34). Controls received more phenylephrine on cardiopulmonary bypass (mean 2.1 vs. 1.4 mg, p<0.001) and had lower nadir oxygen delivery (mean 241 vs. 301 mL O2/min/m2, p<0.001). AKI incidence was 23.9% in controls and 9.1% in GDP patients (p=0.008); incidences of AKI stage 1, 2, and 3 were 19.3%, 3.4%, and 1.1% in controls, and 5.7%, 3.4%, and 0% in GDP patients. Control patients exhibited a larger median percent increase in creatinine from baseline (27% vs. 10%, p<0.001). Conclusions GDP was associated with a reduced AKI incidence following cardiac surgery in this pilot study.
Dr Blalock's unfinished business Shah, Ashish S.
The Journal of thoracic and cardiovascular surgery,
September 2017, 2017-09-00, 20170901, Letnik:
154, Številka:
3
Journal Article
Background
Intracranial pressure (ICP) is an important physiological parameter in several neurological disorders. Considerable effort has been made to measure ICP noninvasively. MR‐based ICP (MR‐ICP) ...is a nonempirical method based on principles of cerebrospinal fluid (CSF) physiology, where ICP is obtained from measurements of blood and CSF flows to and from the cranium during the cardiac cycle.
Purpose
To compare MR‐ICP with invasive ICP measurements obtained using lumbar puncture (LP) or external ventricular drainage (EVD).
Study Type
Prospective, cross‐sectional, observational study.
Subjects
Ten cognitively healthy elderly subjects (age 69.6 ± 6.6 years; seven females) and six brain trauma patients (age 36.8 ± 19.7 years; two females).
Field Strength
Velocity encoding cine phase‐contrast at 1.5 T and 3 T.
Assessment
MR‐ICP and craniospinal compliance distribution were estimated from arterial inflow and venous outflow to and from cranium, and craniospinal CSF flow at the upper cervical region, measured using cine phase contrast MRI. LP (done 177 ± 163 days after scan) and EVD measurements (at the time of scan) were performed in lateral recumbent and supine positions, respectively.
Statistical Tests
Linear regression was used to assess the relationships of MR‐ICP with invasive ICP, and the dependency of these measurements on age, weight, height, and BMI. A Shapiro–Wilks test and Bland–Altman plot were respectively used to evaluate the normality and agreement between these two pressure distributions. Student's t‐test was used throughout the analysis to compare differences between the EVD and LP cohorts.
Results
In the combined cohort, MR‐ICP and invasive ICP were positively correlated (r = 0.95, P < 0.001), with invasive ICP being higher than MR‐ICP by 2.2 mmHg on average. In the healthy cohort, the cranial contribution to total craniospinal compliance was negatively correlated with MR‐ICP (r = −0.90, P < 0.001).
Data Conclusion
MR‐ICP provides a reliable estimate of ICP, with 14 out of 16 datapoints within the clinically acceptable error. Craniospinal compliance distribution plays a role in modulating ICP in supine position.
Level of Evidence: 3
Technical Efficacy: Stage 2
J. Magn. Reson. Imaging 2019;50:975–981.
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