Reliable stratification of the risk of early mortality after postcardiotomy veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) remains elusive. In this study, we externally validated the ...PC-ECMO score, a specific risk scoring method for prediction of in-hospital mortality after postcardiotomy V-A-ECMO. Overall, 614 patients who required V-A-ECMO after adult cardiac surgery were gathered from an individual patient data meta-analysis of nine studies on this topic. The AUC of the logistic PC-ECMO score in predicting in-hospital mortality was 0.678 (95%CI 0.630–0.726; p < 0.0001). The AUC of the logistic PC-ECMO score in predicting on V-A-ECMO mortality was 0.652 (95%CI 0.609–0.695; p < 0.0001). The Brier score of the logistic PC-ECMO score for in-hospital mortality was 0.193, the slope 0.909, the calibration-in-the-large 0.074 and the expected/observed mortality ratio 0.979. 95%CIs of the calibration belt of fit relationship between observed and predicted in-hospital mortality were never above or below the bisector (p = 0.072). The present findings suggest that the PC-ECMO score may be a valuable tool in clinical research for stratification of the risk of patients requiring postcardiotomy V-A-ECMO.
Introduction: Bleeding after transcatheter aortic valve replacement (TAVR) has a negative impact on the outcome of the procedure. Risk factors for bleeding vary widely in the literature, and the ...impact of preoperative antithrombotic agents has not been fully established. The objectives of our study were to assess bleeding after TAVR as defined by the Valve Academic Research Consortium-2 (VARC-2), identify its risk factors, and correlate with antithrombotic treatment in addition to its effect on procedural mortality. Methods: The study included 374 patients who underwent TAVR from 2009 to 2018. We grouped the patients into four groups according to the VARC-2 definition of bleeding. Group 1 included patients without bleeding (n=265), group 2 with minor bleeding (n=22), group 3 with major bleeding (n=61), and group 4 with life-threatening bleeding (n=26). The median age was 78 (25th-75th percentiles: 71-82), and 226 (60.4%) were male. The median EuroSCORE was 3.4 (2-6.3), and there was no difference among groups (P=0.886). The TAVR approach was transfemoral (90.9%), transapical (5.6%), and trans-subclavian (1.9%). Results: Predictors of bleeding were stroke (OR: 2.465; P=0.024) and kidney failure (OR: 2.060; P=0.046). Preoperative single and dual antiplatelet therapy did not increase the risk of bleeding (P=0.163 and 0.1, respectively). Thirty-day mortality occurred in 14 patients (3.7%), and was significantly higher in patients with life-threatening bleeding (n=8 30.8%; P<0.001). Conclusion: Bleeding after TAVR is common and can be predicted based on preprocedural comorbidities. Preprocedural antithrombotic therapy did not affect bleeding after TAVR in our population.
Background: Pain management remains an integral part of patient care after cardiac surgery, and it required proper pain assessment. The aim of the study was to assess pain perception using validated ...Arabic version of the short-form McGill Pain Questionnaire (SF-MPQ) and to identify analgesics prescribing patterns post cardiac surgery.
Methods: This is a prospective study conducted in an adult cardiac critical care unit of a tertiary cardiac center from September 2018 to March 2019. The study enrolled 74 patients who underwent cardiac surgical procedures through a median sternotomy.
Results: The mean age of our patients was 57 ± 11 years and 47 (63.5%) were males. Patients described post-cardiac surgery pain as heavy (n = 37; 50%) and tiring-exhausting (n = 49; 66%), mainly at the site of incision (n = 20; 27%). Pain intensity at day 1 according to pain rating index (PRI) and numerical rating scale (NRS) was 7 (25th, 75th percentiles: 2.8-15) and 6 (3-8), respectively. There was a significant change in pain intensity score between 2 days of assessment (PRI: 7 2.8-15 vs 5 2-11 P = 0.010; NRS: 6 (3-8) vs 5 (2-8), P = 0.021). The most common analgesics prescribed were paracetamol (39%) and a combination of tramadol and paracetamol (33.8%).
Conclusion: Pain decreased the second day after cardiac surgery compared to day 1. Paracetamol was the most prescribed analgesic; however, there was an underutilization which might be affected by insufficient pain reporting. Future improvement could focus on multimodal pain management and proper communication of pain experience.
Background
Reoperations are required frequently after the Ross procedure in rheumatic patients. The use of transcatheter aortic valve implantation (TAVI) in those patients could decrease the risk of ...future open procedure; however, the outcome may be affected by the concomitant mitral valve disease, and subsequent mitral reoperation may distort the implanted aortic valve.
Case presentation
We present a female patient who had a beating mitral valve replacement after valve-in-valve TAVI in a patient with prior Ross procedure. Weaning from cardiopulmonary bypass was difficult, and the patient needed extra-cardiac membrane oxygenation (ECMO) and intra-aortic balloon pump because of right ventricular dysfunction. The right ventricular dysfunction could be due to the concomitant coronary artery disease or air embolism during the beating mitral valve surgery. Recovery was gradual, and the patient was discharged after 33 days. Pre-discharge echocardiography showed a maximum gradient of 9 mmHg on the aortic valve and mild paravalvular leak.
Conclusions
Mitral valve replacement in a patient with prior TAVI and the Ross procedure was feasible; it decreased the operative risk and did not distort the implanted aortic valve.
Right ventricular (RV) volume overload increases morbidity and mortality after tetralogy of Fallot (TOF) repair. Surgical strategies like pulmonary leaflets sparing and tricuspid valve repair at time ...of primary repair may decrease RV overload. Our objective is to evaluate early and midterm results of pulmonary leaflets sparing with infundibular preservation and tricuspid valve repair in selected TOF patients with moderate pulmonary annular hypoplasia.
From 2011 to 2016; 46 patients with TOF and moderate pulmonary annular hypoplasia had surgical repair with sparing of the pulmonary valve leaflets. Concomitant tricuspid valve repair was performed in 33 patients (71.8%). Mean age was 13.1 ± 4.8 months, 68% were males (n = 31) and mean weight was 9.5 ± 2.3 kg. Preoperative McGoon ratio was 1.9 ± 0.4 and pulmonary valve z-score ranges from - 2 to - 3. Preoperative pressure gradient of RVOT was 80.9 ± 7.7 mmHg and 10.9% had minor coronary anomalies (n = 5).
All repairs were performed through trans-atrial trans-pulmonary approach. 87% had pulmonary valve commissurotomy (n = 40). Mean cardiopulmonary bypass time was 71 ± 6.3 min and ischemic time 42.4 ± 4.9 min. Hospital mortality occurred in 4.3% (n = 2). Mean RVOT pressure gradient decreased significantly postoperatively (28.8 ± 7.2 mmHg, p-value< .001) and at the last follow up (23.6 ± 1.8 mmHg, p-value< .001). Pulmonary regurgitation progressed by one grade in 2 patients compared to the postoperative grade. 1 patient (2.5%) had late mortality and reintervention was required in 5 patients (12.5%).
Pulmonary leaflets sparing, and tricuspid valve repair are safe for TOF repair with no added morbidity or mortality. These procedures could contribute to reducing right ventricular volume overload over time after TOF repair.
We aimed to compare the outcomes of ECMO with and without IABP for postcardiotomy cardiogenic shock. The study included 103 patients who needed ECMO for postcardiotomy cardiogenic shock. Patients ...were grouped according to the use of IABP into ECMO without IABP (n = 43) and ECMO with IABP (n = 60). The study endpoints were hospital complications, successful weaning, and survival. Patients with IABP had lower preoperative ejection fraction (p = 0.002). There was no difference in stroke (p = 0.97), limb ischemic (p = 0.32), and duration of ICU stay (p = 0.11) between groups. Successful weaning was non-significantly higher with IABP (36 (60%) vs 19 (44.19%); p = 0.11). Predictors of successful weaning were inversely related to the high pre-ECMO lactate levels (OR: 0.89; p = 0.01), active endocarditis (OR: 0.06; p = 0.02), older age (OR: 0.95; p = 0.02), and aortic valve replacement (OR: 0.26; p = 0.04). There was no difference in survival between groups (p = 0.80). Our study did not support the routine use of IABP during ECMO support.
Objective
Surgical site infection (SSI) is a serious complication after coronary artery bypass grafting (CABG). This study was performed to evaluate evidence-based practice and structured ...problem-solving to reduce SSI after CABG.
Methods
An infection control strategy including supervised chlorhexidine gluconate (CHG) showers was implemented from January 2017 to March 2018 for 119 patients undergoing CABG. The controls comprised 244 patients who underwent CABG from 2014 to 2016. Risk factors for SSI were identified, and a problem-focused strategy was used to control SSI. Propensity score matching was used to study the effect of CHG showers on SSI.
Results
SSI occurred in 25 patients (10.25%) in the control group, and the significant risk factors were the postoperative blood glucose level, transfer from an outside hospital, emergency operation, redo sternotomy, a higher American Society of Anesthesiologists score, and the duration of surgery. After implementation of the program, the SSI rate significantly decreased to 3.36%. Patients who had undergone preoperative CHG showers had a significantly lower SSI rate (1.69%) than the matched controls (13.56%).
Conclusion
SSI after CABG can be reduced using evidence-based practice and structured problem-solving to identify risk factors. A preoperative CHG shower is associated with a lower SSI rate after CABG.
Background
Limited data evaluated the outcomes of extracorporeal membrane oxygenation (ECMO) in patients with prosthetic valves. This study aimed to compare the outcomes of ECMO support for ...postcardiotomy cardiogenic shock in patients with mechanical versus bioprosthetic valves.
Methods
This retrospective study included patients with ECMO support for postcardiotomy cardiogenic shock after valve replacement. Patients were grouped into bioprosthetic (n = 49) and mechanical valve (n = 22) groups.
Results
There were no differences in ECMO duration, inotropic support, intra-aortic balloon pump (IABP), stroke, duration of ICU, and hospital stay between groups. Postoperative thrombosis occurred in 2 patients with bioprosthetic valves (5.41%) and 2 with mechanical valves (14.29%), p = .30. All patients with thrombosis had central ECMO cannulation, concomitant IABP, and inotropic support during ECMO. All thrombi were related to the mitral valve. Three patients with thrombi had hospital mortality.
Survival at 6, 12, and 36 months for bioprosthetic valve patients was 30.88%, 28.55%, and 25.34% and for mechanical valves was 36.36% for all time intervals (Log-rank p = .93). One patient had bioprosthetic aortic valve endocarditis after 1 year. Three patients with bioprosthetic valves had structural valve degeneration after 1, 2, and 5 years.
Conclusions
Outcomes of ECMO in patients with prosthetic valves are comparable between bioprosthetic and mechanical valves. Thrombosis might occur in both valve types and was associated with high mortality. ECMO could affect the long-term durability of the bioprosthetic valves.
Background
The debate about the optimal mitral valve prosthesis continues. We aimed to compare the early and late outcomes, including stroke, bleeding, survival, and reoperation after isolated mitral ...valve replacement (MVR) using tissue versus mechanical valves.
Methods
This retrospective cohort study included 291 patients who had isolated MVR from 2005 to 2015. Patients were grouped into the tissue valve group (n = 140) and the mechanical valve group (n = 151).
Results
There were no differences in duration of mechanical ventilation, hospital stay, and hospital mortality between groups. Fifteen patients required cardiac rehospitalization, nine in the tissue valve group, and six in the mechanical valve group (p = .44). Stroke occurred in nine patients, five with tissue valves, and four with mechanical valves (p = .66). Bleeding occurred in 22 patients, seven patients with tissue valves, and 15 patients with mechanical valves (p = .09). Freedom from reoperation was 95%, 93%, 84%, 67% at 3, 5, 7, and 10 years for tissue valve and 97%, 96%, 96%, and 93% for mechanical valves, respectively (p˂ .001). The median follow‐up was 84 months (Q1: Q3: 38–139). Survival at 3, 5, 7, and 10 years was 94%, 91%, 89%, 86% in tissue valves and 96%, 93%, 91%, 91% in mechanical valves, respectively (p = .49).
Conclusions
Tissue valve degeneration is still an issue even in the new generations of mitral tissue valves. The significant risk of reoperation in patients with mitral tissue valves should be considered when using those valves in younger patients. Mechanical valves remain a valid option for all age groups.
Background
Ventricular fibrillation (VF) is a well‐known ominous complication of ischemic heart disease. While firmly structured algorithms have been developed for its management, yet its mortality ...rate remains high.
Case Presentation
This is a case report of a 46‐year‐old gentleman who was a victim of recurrent cardiac arrest in the ward while awaiting coronary artery bypass grafting (CABG) surgery. Emergency CABG was performed, intraoperatively he experienced recurrent VF which was reverted by direct current cardioversion‐Defibrillation. He was sent to the Cardiac Surgery Intensive Care Unit (CSICU) with an open chest on extracorporeal membrane oxygenation (ECMO) support and an intra‐aortic balloon pump. Postoperatively in CSICU he still experienced malignant ventricular arrhythmia with dropping of ejection fraction to less than 10%. The last few episodes of VF were lengthy, lasting more than an hour (while on ECMO support) with the failure of various antiarrhythmic medications to abort them. Eventually, a decision was made to give him 20 mmol boluses of potassium chloride (KCl) intravenously aiming at introducing a state of asystole, but the rhythm changed to sinus rhythm.
Conclusions
This report highlighted the fact that optimum management of VF is still lacking and necessitates more studies. The appropriate effective dose of potassium replacement during VF might need to be reconsidered in patients with persistent VF.
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