Heart Surgery Forum最新文献

No abstract present.

Objectives: Prolongation of cardiac repolarization, especially the heart rate-corrected QT (QTc) interval, is associated with life-threatening dysrhythmias. This study aimed to identify the anesthetic with the lowest risk of prolonging cardiac repolarization and provide guidance for anesthesia management in patients with cardiac diseases or long QT syndrome.

Methods: Randomized controlled trials (RCTs) comparing the effects of anesthetics on cardiac repolarization indices were searched for in multiple databases. The primary outcome was QTc; and the secondary outcomes were other repolarization indices. A network meta-analysis was conducted using a frequentist approach and registered with the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42022304970).

Results: Thirteen RCTs investigating 953 adults with normal QTc interval and without cardiovascular diseases were included. Direct meta-analyses found that propofol had less influence than sevoflurane (95% confidence interval (CI): 16.10, 33.54) and desflurane (95% CI: 4.85, 35.36), and sevoflurane had less influence than desflurane (95% CI: 6.96, 19.39) on QTc prolongation. Network analysis found that propofol had less influence than sevoflurane (95% CI: 17.78, 29.63), halothane (95% CI: 11.29, 41.24), desflurane (95% CI: 23.79, 39.88), and isoflurane (95% CI: 20.11, 46.10), and sevoflurane had less influence than desflurane (95% CI: 0.43, 15.82) on QTc prolongation. The rank order of cumulative ranking curve analysis was propofol (100%), sevoflurane (63.8%), halothane (49.5%), desflurane (21.1%), and isoflurane (15.6%). The direct meta-analysis found that propofol had less influence than sevoflurane on QT prolongation (95% CI: 23.12, 57.86). Other secondary outcomes showed no conclusive findings.

Conclusions: This meta-analysis found that propofol had a minimal effect on QTc prolongation, followed by sevoflurane and desflurane in adults with normal QTc interval and without cardiovascular diseases. Propofol is the best anesthetic for adult patients with long QT syndrome or cardiac diseases, but still needs more robust evidence.

Objective: The ideal type of hospital to care for adult congenital heart disease (ACHD) patients is not well known. Hospital competitiveness, clinical volume and market structure can influence clinical outcomes. We sought to understand how hospital competitiveness affects clinical outcomes in ACHD patients in the era prior to the Adult Congenital Heart Association accreditation program.

Methods: Patient discharges with ACHD diagnosis codes were filtered between 2006-2011 from an all-payer inpatient healthcare database. Hospital-level data was linked to market structure patient flow. A common measure of market concentration used to determine market competitiveness-the Herfindahl-Hirschman Index (HHI)-was stratified into: more competitive (HHI ≤25th percentile), moderately competitive (HHI 25th to <75th percentile), and less competitive (HHI ≥75th percentile) hospital. Any complication, home discharge and mortality were analyzed with clustered mixed effects logistic regression. The combined impact of HHI and any complication on mortality by interaction was assessed.

Results: A total of 67,434 patient discharges were isolated. More competitive hospitals discharged the least number of patients (N = 15,270, 22.6%) versus moderately competitive (N = 36,244, 53.7%) and less competitive (N = 15,920, 23.6%) hospitals. The adjusted odds of any complication or home discharge were not associated with hospital competitiveness strata. Compared to more competitive hospitals, mortality at moderately competitive hospitals (Adjusted Odds Ratio (AOR) 0.79, 95% CI: 0.66-0.94) and less competitive hospitals (AOR 0.79, 95% CI: 0.63-0.98) were lower (p = 0.025). Age, race, elective admission, transfer status, and payer mix were all significantly associated with adjusted odds of any complication, home discharge and mortality (p ≤ 0.05). Having any complication independently increased the adjusted odds of mortality more than 6-fold (p < 0.001), and this trend was independent of HHI strata. Failure to rescue an ACHD patient from mortality after having any complication is highest at less competitive hospitals. Sensitivity analysis which excluded the transfer status variable, showed that any complication (p = 0.047) and mortality (p = 0.01) were independently associated with HHI strata.

Conclusions: Whether lower competition allow hospitals to focus more on quality of care is unknown. Hospital competitiveness and outcome seem to have an inverse trend relationship among ACHD patients. Since medical care is frequently provided away from the home area, hospital selection is an important issue for ACHD patients. Further research is needed to determine why competitiveness is linked to surgical outcomes in this population.

Background: The elderly population is growing at an unprecedented rate. Aortic valve disease increases with age. Bioprostheses are the valves of choice for older patients; however, the optimal tissue valve remains undetermined. The purpose of this investigation was to perform a life-of-patient survival comparison of the prototypical porcine and pericardial prostheses in elderly patients.

Methods: The study population (N = 1480) consisted of patients 65 years of age and older who underwent isolated aortic valve replacement from 1990 through 2005 with a Carpentier-Edwards Porcine (n = 650) or Pericardial (n = 830) bioprosthesis. Propensity score-matched groups were created.

Results: Valve selection was not associated with operative mortality. Survival estimates at 10 years were better for Pericardial (41.8%; 95% CI: 37.9 to 45.7) than Porcine (32.6%; 95% CI: 28.8 to 36.3); and 5.2% (95% CI: 3.2 to 7.1) versus 2.0%; (95% CI: 0.8 to 3.2) at 20 years (p < 0.001). E-value analysis found minimal influence of unknown study confounders. Factors associated with long-term mortality were porcine valve (p < 0.001), age (p < 0.001), diabetes mellitus (p < 0.001), preop renal insufficiency (p < 0.001), peripheral artery disease (p = 0.011), congestive heart failure (p = 0.003), New York Heart Association Class III or IV (p = 0.004), surgical history-reoperation (p = 0.012), transient ischemic attack (p = 0.009), prolonged ventilation (p = 0.010), postop renal insufficiency (p < 0.001), and atrial fibrillation (p = 0.009). The indexed Effective Orifice Area (EOAi) was assessed and did not influence observed long-term survival differences.

Conclusions: This unusual lifetime study provided substantial evidence for the superiority of the pericardial over the porcine bioprosthesis in the aortic position in elderly patients. It demonstrated enhanced long-term survival benefits for elderly patients without any increase in perioperative mortality. It is intended to inform future investigation into aortic valve design.

Aim: This study aims to explore the effects of home-based remote cardiac rehabilitation on left ventricular function and exercise fear in patients after percutaneous coronary intervention (PCI).

Methods: A total of 232 patients with coronary heart disease after PCI treated in Tianshan Traditional Chinese Medicine Hospital from January 2020 to December 2022 were retrospectively analyzed. The patients were divided into the remote rehabilitation group (169 cases) and the routine group (63 cases) according to the exposure factor (home-based remote cardiac rehabilitation). Changes in left ventricular function and sports phobia Tampa Scale in patients with coronary heart disease after PCI were compared using propensity score matching to reduce selection bias and confounding factors.

Results: After the intervention, the scores of patients in the tele-rehabilitation group were significantly higher than those in the conventional group in terms of fear of movement, perception of danger, fear of movement, avoidance of movement, and dysfunction (p-value < 0.05). Left heart function was compared between the tele-rehabilitation group and the conventional group. Patients in the tele-rehabilitation group had significantly higher peak mitral valve blood flow in the early diastolic period (E), peak mitral valve blood flow in the late diastolic period (A), six-minute walk test (6MWT), and ratio of the peak mitral valve blood flow in the early diastolic period to the peak mitral valve blood flow in the late diastolic period (E/A) than those in the conventional group (p-value < 0.05). However, the peak deceleration time and isovolumic diastolic time in the early mitral valve diastolic period were significantly higher in the tele-rehabilitation group than in the conventional group (p-value < 0.05).

Conclusions: Home-based remote cardiac rehabilitation instruction can improve the heart function and exercise fear state of patients after PCI.

Objective: This study aimed to explore and analyze the factors affecting the incidence of pneumonia after coronary artery bypass grafting (CABG) to provide reference for the prevention of such situation.

Methods: A total of 500 patients who underwent CABG in a hospital were selected. From March 2019 to March 2022, 410 patients without pneumonia and 90 patients with pneumonia were divided into groups A and B. The influencing factors and pathogen composition of postoperative pneumonia were discussed and analyzed.

Results: Univariable analysis results showed that age, cardiac function grade, occurrence of smoking, operation time, tracheal intubation time, suspended red-blood-cell transfusion and hospital stay in group B were higher than those in group A. Multivariable logistic analysis results showed that operation time, smoking history, and tracheal intubation time were risk factors for pneumonia after CABG. Among the 90 patients with postoperative pneumonia, 90 had pathogens, 81 had Gram-negative bacteria, 4 had Gram-positive bacteria, and 5 had fungi.

Conclusions: Patients after CABG were more likely to develop pneumonia. Operation time, smoking history, and tracheal intubation time were the risk factors of pneumonia after CABG. Most of these patients had Gram-negative bacteria. Patient intervention based on the influencing factors can effectively prevent the occurrence of postoperative pneumonia.

Background: When acute coronary syndrome patients necessitate immediate revascularization, heart-on-pump coronary artery bypass grafting may be regarded as a viable substitute for conventional on-pump surgery. Our clinical experience and initial outcomes of heart-on-pump coronary surgery in patients with acute coronary syndrome are detailed in this article.

Method: This research endeavor was a retrospective analysis that spanned the years March 2011 to August 2023. The sample size comprised 2816 patients who had undergone coronary artery surgery. During this period, the same surgical team performed coronary artery bypass surgery on 411 of these patients, who underwent beating heart surgery while on cardiopulmonary bypass support and without cardioplegic arrest; this was done under emergency conditions.

Result: 9.3 ± 2.2 hours elapsed between the initiation of acute myocardial infarction and the commencement of coronary artery bypass grafting (CABG). A mean of 4.0 grafts was applied (2.2 ± 1.1). Mortality in hospitals was calculated for sixteen patients. Following surgery, twenty-six patients developed an inadequate cardiac output syndrome. Despite having renal dysfunction, none of the eight individuals needed hemodialysis. The mean duration of stay in intensive care was 3.2 (2.2 ± 1.1) days, while the mean length of hospitalization was 9.2 (4.3 ± 2.4) days.

Conclusion: We believe that for high-risk patients with multivascular coronary artery disease who require an emergency coronary artery bypass graft, on-pump beating heart revascularization could be a viable option.

Background: Cardioplegia solutions are used to protect the myocardium from ischemic injury caused by cardiopulmonary bypass and various types of cardioplegia solutions have been introduced for cardiac surgery. In this study, we aimed to compare the effects of del Nido cardioplegia and microplegia, which were mostly used in our clinic for intraoperative and postoperative processes among patients who underwent elective mitral valve replacement. As a result, the comparison could be performed in a specific patient group without additional valvular or coronary disease, and cardioplegia distribution could be achieved more efficiently.

Methods: Between 2018 and 2023, a total of 120 patients who underwent elective mitral valve replacement via sternotomy with del Nido cardioplegia or microplegia were included in the study. Patients were divided into two groups; group 1 (del Nido, n = 64) and group 2 (microplegia, n = 56). Preoperative characteristics, intraoperative and postoperative early clinical data as primary outcomes, and postoperative mortality rates and intensive care costs as secondary outcomes were compared statistically.

Results: There were no statistically significant differences in terms of preoperative characteristics between the two groups. Duration of cross clamp differences between group 1 versus group 2 (45 ± 16 vs. 57 ± 19 min), cardiopulmonary bypass (56 ± 17 vs. 65 ± 21 min), intensive care length of stay (18.04 ± 7.41 vs. 22.37 ± 6.86 h), requirement of intraoperative defibrillation (n = 5 vs. n = 13), and intensive care costs were found to be statistically significantly lower in del Nido group.

Conclusion: Either del Nido or microplegia solutions can be used safely in mitral valve replacement operations, however, del Nido cardioplegia has some advantages over intraoperative processes, such as lowering the cross clamp and cardiopulmonary bypass time. Furthermore, patients who received del Nido cardioplegia had shorter intensive care stay and required less intraoperative defibrillation compared with the microplegia group. Therefore, less exposure to anesthesia, the prevention of infection due to shortened operation duration, and greater cost-effectiveness can be achieved by using del Nido cardioplegia instead of microplegia.

Background: The aim of this work was to create a novel model for predicting acute kidney injury (AKI) after off-pump coronary artery bypass graft (OPCABG).

Methods: The individuals who underwent OPCABG were randomly separated into a derivation group and a validation group, at a 7:3 ratio. The primary outcome was AKI under the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. To optimize feature selection and construct a nomogram, both least absolute shrinkage and selection operator regression (LASSO) and logistic regression analysis were utilized. The nomogram was assessed in various ways: with the C-index, calibration curve, decision curve analysis (DCA), and clinical impact curve analysis (CICA).

Results: The use of an intra-aortic balloon pump (IABP), systolic blood pressure, smoking and baseline serum creatinine were identified as independent impact factors. The C-index of the nomogram was 0.733 (95% confidence interval (CI) = 0.669-0.791) and 0.786 (95% CI = 0.693-0.878) in the training and validation groups, respectively. The area under the curve (AUC) of the internal validation was 0.715 using bootstrapping with 1000 replicates. The calibration plot revealed that the predicted outcomes aligned well with the observations. DCA and CICA suggested that the model had clinical benefit.

Conclusion: The nomogram that relied on clinical characteristics proved to be a dependable instrument to predict AKI after OPCABG. This model is conveniently applicable in clinical settings and will be a valuable resource for assessing timely medical measures to mitigate risk.

Objective: To observe clinical efficacy of fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) in coronary heart disease patients with SYNTAX scores (SS) ≥33 and Euro Scores (ES) ≥6 who are unsuitable for or have declined coronary artery bypass graft (CABG).

Methods: A total of 117 patients with SS ≥33 and Euro Score (ES) ≥6 who were unsuitable for and/or who had declined CABG between Jan 2021 and June 2022 were enrolled in this retrospective analysis. All patients accepted optimal medical therapy and some accepted an FFR-guided PCI procedure. Patients who only underwent optimal medical therapy were divided into the optimal medical therapy group (OMT group) and patients who simultaneously underwent FFR-guided PCI procedure were divided into the PCI group in this retrospective analysis. All patients accepted follow-up for at least 12 months after discharge.

Results: SS and ES in the two groups were not statistically different (p > 0.05). Patients with chronic total occlusion accounted for a greater proportion in the PCI subgroup (31.3%, 5/16) than in other subgroups. Eighteen (18.6%, 18/97) cases in the PCI group developed major adverse cardiac and cerebrovascular events (MACCEs). There were 12 (60%, 12/20) cases of MACCEs in the OMT group, which was statistically different from the PCI group (p < 0.05).

Conclusions: Based on optimal medical therapy, FFR-guided PCI can still have clinical benefit to coronary artery disease patients with SS ≥33 who were not suitable for CABG.