Journal of Cardiac Surgery最新文献

Objectives. Aortic arch replacement is a major surgical intervention. This meta-analysis aims to combine the international literature on the branch-first technique to describe its outcomes and offer a comparison to the standard techniques. Methods. PubMed and Cochrane were searched for studies on the branch-first technique in aortic arch surgery including those comparing this technique with the conventional ones. Mortality, neurological complications, bleeding, and renal replacement therapy were the major endpoints of interest. Subgroup analysis was performed for both single- and double-armed studies. Odds ratios with 95% confidence interval were used as summary estimates. The random-effects model was used for all outcomes. Results. Ten studies from three countries with a total of 498 patients were included. Proportional analysis of the branch-first technique estimated mortality of (3%, 95% CI [0.02–0.05]), neurological complications of (8%, 95% CI [0.03–0.13]), re-exploration for bleeding of (9%, 95% CI [0.05–0.13]), and renal replacement therapy of (9%, 95% CI [0.05–0.12]). This meta-analysis revealed no significant differences between the branch-first technique and the conventional technique in mortality (5% vs. 15%, OR = 0.32, 95% CI [0.08–1.18], p = 0.09, I2 = 40%), neurological complications (10% vs. 16%, OR = 0.53, 95% CI [0.24–1.21], p = 0.13, I2 = 0%), or renal replacement therapy (12% vs. 14%, OR = 0.72, 95% CI [0.33–1.59], p = 0.41, I2 = 0%). Conclusions. Branch-first technique provides a promising alternative approach in aortic arch surgery with no different surgical risks and potentially reduced operative complexity. Randomised controlled trials are needed to further investigate the safety and advantages of this technique.

Objectives. To investigate the predictive value of serum cold-inducible RNA-binding protein (CIRP) and postoperative acute kidney injury (AKI) after total aortic arch replacement. Methods. Eighty-six patients with acute Stanford type A aortic dissection (ATAAD) admitted to hospital from October 2019 to February 2021 were retrospectively selected as the study subjects. All patients underwent total aortic arch replacement under moderate hypothermic circulatory arrest (MHCA) with selective antegrade cerebral perfusion (SACP). Detection of the level of serum CIRP after admission and perioperative clinical data of patients were collected and analyzed. Kidney Disease: Improving Global Outcomes (KDIGO) criteria were used to stage renal function. Patients were divided into a non-AKI-3 group (n = 70) and an AKI-3 group (n = 16) according to the stage of postoperative renal function. The risk factors for postoperative AKI KDIGO stage 3 were analyzed by a multivariate logistic regression model. The receiver operating characteristic (ROC) curve was used to evaluate the diagnostic efficacy. Results. In 86 patients, postoperative AKI-3 stage accounted for 18.6% (16/86). Compared with the non-AKI-3 group, the AKI-3 group had a higher preoperative BMI index, C-reactive protein, and CIRP level; a longer intraoperative cooling time, cardiopulmonary bypass time, and aortic cross-clamping time; and a higher intraoperative coronary artery bypass ratio (all P < 0.05). Multivariate logistic regression results showed that CIRP (OR = 1.001, 95% CI: 1.000–1.002, P = 0.012) was an independent risk factor for postoperative AKI KDIGO stage 3. Conclusion. The serum CIRP is associated with postoperative acute kidney injury after total aortic arch replacement in ATAAD patients and may serve as a predictive indicator for early detection and intervention to improve the prognosis.

As surveillance and the diagnosis of pathology grow, increasing numbers of patients are undergoing major aortic interventions globally. As a result, surgeons and physicians will encounter thoracic aortic graft infections with increasing frequency. These infections are extremely challenging, high-risk problems to deal with. This article provides a comprehensive overview of the pathogenesis, diagnosis, and management both medical and surgical of this high-risk complication. We provide proposed diagnostic criteria and suggested algorithm for the management of this important group of patients.

Heart transplantation from donors after circulatory death (DCD) has demonstrated increased primary graft dysfunction. Durable mechanical circulatory (MCS) recipients have slightly higher perioperative risk but excellent long-term survival. We sought to determine if the use of DCD donors impacted outcomes for patients with MCS. The United Network for Organ Sharing database was queried from 2019 to 2023 for all adult recipients who underwent heart transplant with a durable left ventricular assist device (LVAD). Outcomes were compared for recipients of DBD and DCD donors. Kaplan–Meier analysis was used to compare survival. A total of 3449 recipients underwent heart transplant who met the study criteria. The number of DCD and DBD donors was 288 (8.4%) and 3161 (92.6%). There was no difference in the length of stay, postoperative dialysis, pacemaker, stroke rate, or in-hospital mortality. Recipients with durable LVADs of DCD donors had a higher rate of treatment for rejection within the first year. Overall survival was not different between DBD and DCD donors (p = 0.153). Postoperative and survival outcomes for DCD donation remain similar between patients with and without MCS. These findings may help decrease waitlist time for patients with durable MCS.

Objective. The learning curve of coronary artery bypass grafting with multiple arterial grafting and without the use of cardiopulmonary bypass (off-pump) is perceived as an advanced subspeciality associated with increased surgical risk. We compared the trends and early clinical outcomes between trainees and consultants as the first operator in the United Kingdom. Methods. All patients who underwent elective or urgent isolated coronary artery bypass grafting from 1996 to 2019 were extracted from the National Adult Cardiac Surgery Audit database. Trends and early clinical outcomes between trainees and consultants as the first operator were compared in the whole cohort and after propensity score matching. Results. Of the total coronary artery bypass graft procedures, trainees performed 24.39% (n = 79759/327025). Trainees performed 27.10% (63934/235920) on-pump without multiple arterial graft procedures compared to consultants. The consultants had a shorter cardiopulmonary bypass time (82.81 (SD: 35.36) vs 86.21 (SD: 30.07) minutes, p < 0.001) and aortic cross-clamp time (48.05 (SD: 22.46) vs 50.66 (SD: 19.49) minutes, p < 0.001). However, consultants had a higher mortality (1.6% vs 1.0%, p < 0.001) and incidence of postoperative dialysis (2.1% vs 1.5%, p < 0.001). Trainees performed 16.78% (8089/48220) multiple arterial graft procedures, with no differences compared with consultants for in-hospital mortality (1.0% vs 0.9%, p = 0.42), cerebral vascular accident (transient ischaemic attack (0.5% vs 0.5%) and permanent stroke (0.6% vs 0.4%), p = 0.33), return to theatre (4.2% vs 4.47%, p = 0.089), postoperative renal dialysis (1.4% vs 1.1%, p = 0.076), and deep sternal wound infection (0.6% vs 0.6%, p = 0.87). Trainees performed 17.17% (8661/41778) off-pump cases. Consultants had a higher in-hospital mortality (1.2% vs 0.9%, p = 0.045) with no differences in cerebral vascular accident (transient ischaemic attack (0.2% vs 0.3%) and permanent stroke (0.4% vs 0.4%), p = 0.27), return to theatre (3.8% vs 3.9%, p = 0.69), postoperative renal dialysis (2.0% vs 1.6%, p = 0.059), and deep sternal wound infection (1.0% vs 0.8%, p = 0.66). Conclusion. Trainees in the United Kingdom have adequate exposure to advanced coronary surgery without compromising patients’ safety.

Background. Aortic root replacement with a composite mechanical valve graft (Bentall procedure) has been a recommended strategy in patients with aortic root aneurysm with or without aortic regurgitation. Aortic root remodeling (Yacoub procedure) has emerged as a valve-sparing alternative although there is only scarce multicenter evidence. The aim of our study was to provide nationwide comparison of these two strategies. Methods. This was a retrospective study of data from national registry of cardiac surgery. Using propensity-score matching, we compared all the patients undergoing the Bentall procedure in the Czech Republic between 2010 and 2021 with patients after the Yacoub procedure from four experienced centers. Results. During the study period, 199 patients underwent Yacoub and 526 had Bentall procedure. Of those, 166 pairs were selected and compared. There was no significant difference in perioperative outcomes and in mortality (p = 0.96) over the follow-up of 5.7 vs. 6.4 years. The Bentall procedure was associated with a higher risk of major bleeding or thromboembolism (p < 0.001), and the Yacoub procedure led to a higher risk of rehospitalizations for valve failure (p = 0.01). Conclusions. In a nationwide propensity-matched study, Bentall and Yacoub procedures yield similar longer-term survival. Yacoub offers better freedom from thromboembolism or bleeding at the cost of higher risk of valve failure.

Background. The Impella 5.5 offers a less invasive transvalvular approach to left ventricular mechanical support. End-organ recovery and hemolysis have been well-studied with durable left ventricular assist devices but effects of Impella 5.5 on these parameters are less well described. Methods. All Impella 5.5 recipients between August 2020 and June 2023 were reviewed from a single institution. Hemodynamics and laboratory values were compared between preimplant and prior to device removal. Hemolysis was defined as postoperative lactate dehydrogenase >1000 IU/L with concurrent plasma-free hemoglobin >50 mg/dL. Paired Wilcoxon tests compared the median of differences between preimplant and pre-explant values. Results. We studied 127 consecutive implants of the Impella 5.5. Thirty-one patients had concomitant VA-ECMO, and one received Impella 5.5 after durable LVAD explant; these cases were excluded. Our final cohort included 95 patients, with an average age of 55.29 ± 14.5 years. Median implant duration was 11 days (IQR:6–16 days). To avoid confounding hemodynamic factors, we restricted hemodynamic analysis to the 37 patients who received isolated Impella 5.5, excluding those with prior IABP, Impella CP, acute MI, or prior cardiac surgery. These patients experienced improvements from baseline in pulmonary vascular resistance (−77.03 dynes/sec/cm⁻⁵, p < 0.01) and wedge pressure (−6.5 mmHg, p < 0.01). Furthermore, cardiac index improved from baseline (+1.3, p < 0.01). In the total cohort (n = 95), pre-explant creatinine (−0.2 mg/dL, p < 0.01) and ALT (−9.0 mg/dL, p < 0.01) decreased relative to values before the implant. Twenty-three (24%) met criteria for hemolysis; however, none underwent device removal for clinically significant hemolysis. Takeback was required in 25 patients, 22 of which were for axillary hematoma. Conclusions. Impella 5.5 support acutely improved markers of end-organ function and hemodynamics, including PVR.

Background. Previous research has only conducted a restricted amount of investigations on the effectiveness of propafenone in preventing and treating of atrial fibrillation (AF) after cardiac surgery. Hence, a comprehensive evaluation and meta-analysis were performed to evaluate the effectiveness and safety of propafenone in individuals undergoing cardiac surgery for postoperative atrial fibrillation (POAF). Methods. A meta-analysis of randomized controlled trials was conducted. Until September 15th, 2023, various databases were searched. The main focal points consisted of the presence of POAF, transition from AF to sinus rhythm, and reappearance of AF. The odds ratios (ORs) for treatment effects on dichotomous variables were calculated. Results. The analysis of data included 9 controlled trials that were randomized and had 1014 patients. The findings indicated that propafenone has a significant impact on reducing the occurrence of POAF in adult patients who undergo cardiac surgery (OR, 0.52; 95% CI: 0.30, 0.89; P = 0.02). In addition, it was observed that propafenone significantly increase the rate of conversion to sinus rhythm from AF within 20 min (OR, 5.39; 95% CI: 2.25, 12.91; P = 0.0002) and 1 hour (OR, 2.89; 95% CI: 1.50, 5.57; P = 0.002) after administration. Surprisingly, the administration of propafenone treatment did not have a significant impact on the rate of conversion to sinus rhythm from AF within 24 hours (OR, 0.63; 95% CI: 0.38, 1.04; P = 0.07) after administration. Conclusions. The present study suggests that the postoperative administration of propafenone to adult cardiac surgery patients is both safe and effective for preventing and treating POAF.

Background. Surgical mobilization of the internal mammary artery (IMA) can induce graft vasospasm, which is commonly managed by wrapping the IMA in a vasodilator-soaked swab before grafting. However, the choice of the most effective topical vasodilator remains the subject of continued investigation. We carried out a prospective randomized controlled trial to compare the effect of topically applied milrinone, nitroglycerin, and normal saline on IMA free flow. Methods. Forty-six consecutive patients undergoing elective primary coronary artery bypass grafting were enrolled. After the left IMA was harvested, free flow was measured under controlled hemodynamic conditions before any intervention (flow 1) and at a mean of 12.5 minutes after the topical application of one of three agents (milrinone, nitroglycerin, or normal saline) on the IMA (flow 2). Results. All agents induced a significant increase in IMA flow, and flow 2 was significantly higher in the nitroglycerin and milrinone groups compared to the normal saline group, even while controlling for flow 1 as a centered continuous variable. Nevertheless, there was no statistically significant difference in flow 2 between the nitroglycerin and milrinone groups. Conclusions. Topically applied milrinone and nitroglycerin can increase blood flow of the IMA significantly in the early period after surgical mobilization. IMA blood flow was greater after the topical application of milrinone compared to nitroglycerin, but this has failed to reach statistical significance in the present study setting. This trial is registered with NCT06301880.

Objective. Introduction of minimally invasive cardiac surgery anticipated the reduction in postoperative pain but little quantitative data are available on this effect. This study investigated factors influencing pain scores and opioid demand after robotically assisted cardiac procedures. Methods. Using data derived from prospective robotic cardiac surgery and anesthesia databases, we analyzed 75 patients undergoing robotic cardiac surgery between July 2021 and December 2022. Study endpoints were mean cumulative pain scores measured on a 0–10 scale and opioid use on postoperative days (PODs) 1 to 4. Pain scores and oral morphine equivalent (OME) were correlated with perioperative variables. Results. Postoperatively, 39/75 (52%) of patients were extubated in the operating room (OR) and 34/75 (45.3%) were extubated within 24 hours of surgery. Mean pain scores declined from 5.8 (SD 1.5) on POD 1 to 3.8 (SD 1.6) on POD 4 and OME fell from 34.9 (SD 29) mg to 8.2 (SD 11.8) mg. OME use correlated significantly with pain scores (p < 0.01). Higher pain scores on postoperative day (POD) 1 were associated with diabetes (p = 0.006), tobacco use (p = 0.006), and extubation in the OR (p = 0.017). Opioid utilization was higher in younger patients (p < 0.001), heavier patients (p = 0.033), active tobacco users (p = 0.01), longer procedure times (p = 0.002), and those extubated in the OR (p < 0.001). Conclusion. Pain and opioid consumption after robotically assisted cardiac surgery are moderate but decline steadily within the first four postoperative days. Tobacco use and extubation in the OR were associated with increased pain and opioid consumption.