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To evaluate the incremental prognostic value of longitudinal strain over left ventricular ejection fraction (LVEF) after coronary artery bypass grafting (CABG).Retrospective cohort study.Single tertiary-care center.Patients underwent isolated CABG between January 2014 and December 2019.None.There were 999 patients (median age, 65 years, 23.5% female) categorized into 3 groups according to their left ventricular (LV) systolic function status: pEF/pS (preserved LVEF and preserved longitudinal strain, n = 490), pEF/iS (preserved LVEF and impaired longitudinal strain, n = 186), and rEF (reduced LVEF, n = 323). During a median follow-up of 2.7 years, 86 (8.6%) patients had died. The 5-year survival significantly differed in patients with preserved LVEF according to the strain status (pEF/pS v pEF/iS, 90.0% v 84.6%; p = 0.002). After adjusting for potential confounders, the pEF/iS group (adjusted hazard ratio [HR], 2.17; 95% CI, 1.10-4.28; p = 0.03) and the rEF group (adjusted HR, 2.96; 95% CI, 1.46-6.00; p = 0.003) had significantly higher risks for all-cause death compared with the pEF/pS group. The addition of longitudinal strain to LVEF in the prediction model significantly improved its performance (global chi-squared, 105.2 v 110.2; p = 0.03).Left ventricular longitudinal strain could differentiate the prognosis after CABG in patients with preserved LVEF and provide significant incremental prognostic value to LVEF.

Melatonin has emerged as an anti-inflammatory agent, potent direct free-radical scavenger, and an indirect antioxidant in preventing ischemia-reperfusion injury. This study aimed to evaluate melatonin's effect on cardiac biomarkers after coronary artery bypass grafting (CABG).A double-blind, randomized placebo-controlled pilot clinical study.Booali Sina Hospital, Qazvin University of Medical Sciences, Qazvin, Iran.One hundred patients undergoing elective CABG. The patients were divided randomly into control (C) and melatonin (M) groups (50 patients per group).The M group received 3 mg of melatonin the night before surgery, 3 mg in the morning, and routine cardiac surgery medications. The C group received 1 placebo tablet rather than melatonin. After surgery, the patients in the M group received 3 mg of melatonin, and the C group received 1 placebo tablet at bedtime until the third day after CABG.In both groups, creatine kinase-MB (CPK-MB), cardiac troponin I, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were measured before surgery and on the first, second, and third postoperative days. Serum CPK-MB levels on the second and third day after CABG were significantly lower in the M group than in the C group (p0.05). Regarding cardiac troponin I, CRP, and ESR markers, there were no significant changes in serum concentration before surgery and on the first, second, and third days after surgery between the 2 groups (p0.05). The mean length of hospitalization in the ICU was lower in the M group (3.4 ± 1.05) compared with the C group (3.96 ± 1.06, p = 0.01).Melatonin reduced the postoperative level of CPK-MB and the length of hospitalization in the ICU in patients who underwent cardiac surgery.

To evaluate whether enhanced recovery after surgery (ERAS) protocol implementation was associated with improved outcomes and decreased racial and ethnic outcome disparities after isolated coronary artery bypass graft (CABG) surgery.A retrospective analysis of an institutional CABG database with propensity-score matching.At a single tertiary care teaching hospital.One thousand seven hundred thirty-five patients undergoing isolated CABG: 656 patients from 2016 to 2017 (pre-ERAS) and 1,079 patients from 2018 to 2020 (post-ERAS). Each patient cohort was divided into a White subgroup and a racial and ethnic minorities (Minorities) subgroup.None MEASUREMENTS AND MAIN RESULTS: Propensity-matched post-ERAS patients (n = 584) compared to pre-ERAS patients (n = 584) demonstrated reductions in total length of stay (LOS) (median [interquartile range]): (7 [5-10] v 8 [6-11.5] days, p = .006), postoperative LOS (5 [4-7] v 5 [4-7] days, p = .001), total ventilation time (6.1 [4.8-9.5] v 6.6 [5.2-10.9] hours, p = .004), postoperative morphine milligram equivalents (mean ± standard deviation: 68.6 ± 57.5 v 100.0 ± 59.4, p.001), and increased likelihood of early extubation (48.8% v 42.3%, p = .026); the Minorities subgroup demonstrated reductions in likelihood of intensive care unit (ICU) readmission (1.3% v 8.1%, p = .012) and postoperative morphine milligram equivalents (73.6 ± 64.0 v 107.8 ± 71.9, p.001). Logistic regression models demonstrated that disparities in ICU readmission and postoperative LOS between White and Minorities patients were eliminated post-ERAS.ERAS for isolated CABG surgery was associated with reduced total and postoperative LOS, reduced total ventilation time, and increased early extubation for all patients, as well as reduced ICU readmission for the Minorities subgroup. ERAS implementation was associated with reduced disparities between White and racial and ethnic minority patients for ICU readmission and postoperative LOS.

Objective It is unknown if remaining intubated after cardiac surgery is associated with a decreased risk of postoperative reintubation. The primary objective of this study was to investigate whether there is an association between the timing of extubation and the risk of reintubation after cardiac surgery. Design A retrospective, observational study. Setting Two university affiliated tertiary care centers. Participants 9,517 patients undergoing either isolated coronary artery bypass grafting (CABG) or aortic valve replacement (AVR). Intervention None Measurements and Main Results A total of 6,609 isolated CABGs and 2,908 isolated AVRs were performed during the study period. Reintubation occurred in 112 patients (1.64%) after CABG and 44 patients (1.5%) after AVR. After multivariable logistic regression analysis, early extubation (within the first 6 post-operative hours) was not associated with risk of reintubation after CABG (OR 0.53, 95% CI 0.26-1.06) and AVR (OR 0.52, 95% CI 0.22-1.22). Risk factors for reintubation included increased age in both the CABG (OR per 10 year increase, 1.63; 95% CI, 1.28-2.08) and AVR (OR per 10 year increase, 1.50; 95% CI, 1.12-2.01) cohorts. Total bypass time, race, and New York Heart Association (NYHA) functional class were not associated with reintubation risk. Conclusion Reintubation after CABGs and AVRs is a rare event, and advanced age is an independent risk factor. Risk is not increased with early extubation. This temporal association and low overall rate of reintubation suggest the strategies for extubation should be modified in this patient population.

Circulating cardiac biomarkers may improve the prediction of long-term outcomes after cardiac surgery. The authors sought to assess if cardiac biomarkers also help better predict short-term morbidity.Prospective observational study.Single academic hospital.A total of 250 patients undergoing aortic or mitral valve surgery with or without associated coronary artery bypass grafts.None MEASUREMENT AND MAIN RESULTS: Relationships between preoperative plasma concentrations of four cardiac biomarkers (sST2, Galectin-3, GDF-15, and NT-proBNP) and postoperative outcome were assessed using logistic regressions and Cox proportional hazards models. The primary outcome was a composite of 30-day mortality, an inotropic support longer than 48 hours and an initial length of stay in the intensive carefive days. Secondary outcome measures were postoperative acute kidney injury, inotropic support duration, lengths of intensive care unit and hospital stays, and 30-day and one-year mortality. No association was observed between any of the four cardiac biomarkers and the primary outcome. The preoperative levels of Galectin-3 (hazard ratio = 1.2; p0.001) and sST2 (hazard ratio = 1.01, p0.001) were significantly associated with one-year survival, and their addition to the EuroSCORE II significantly improved the prediction of one-year mortality (p0.001). Similarly, Galectin-3 was associated with postoperative acute kidney injury (odds ratio = 1.15, p = 0.001) and improved the prediction of this complication when added to the EuroSCORE II (p = 0.002).These results suggested that the ability of cardiac biomarkers to predict short-term outcome after cardiac surgery, though of interest, appears limited. Conversely, cardiac biomarkers may have the potential to refine the prediction of long-term outcome. Admittedly, all positive results were obtained on secondary outcomes and must be regarded with caution.

Objectives To assess the ability of the biomarkers neuron-specific enolase (NSE), tau, neurofilament light chain (NFL), and glial fibrillary acidic protein (GFAP) to predict postoperative cognitive dysfunction (POCD) at discharge in patients who underwent cardiac surgery. Design Post hoc analyses (with tests being prespecified before data analyses) from a randomized clinical trial. Setting Single-center study from a primary heart center in Denmark. Participants Adult patients undergoing elective or subacute on-pump coronary artery bypass grafting and/or aortic valve replacement. Interventions Blood was collected before induction of anesthesia, after 24 hours, after 48 hours, and at discharge from the surgical ward. The International Study of Postoperative Cognitive Dysfunction test battery was applied to diagnose POCD at discharge and after three months. Linear mixed models of covariance were used to assess whether repeated measurements of biomarker levels were associated with POCD. Receiver operating characteristic (ROC) curves were applied to assess the predictive value of each biomarker measurement for POCD. Measurements and Main Results A total of 168 patients had biomarkers measured at baseline, and 47 (28%) fulfilled the POCD criteria at discharge. Patients with POCD at discharge had significantly higher levels of tau (p = 0.02) and GFAP (p = 0.01) from baseline to discharge. The biomarker measurements achieving the highest area under the ROC curve for prediction of POCD at discharge were NFL measured at discharge (AUC, 0.64; 95% confidence interval [CI], 0.54-0.73), GFAP measured 48 hours after induction (AUC, 0.64; 95% CI, 0.55-0.73), and GFAP measured at discharge (AUC, 0.64; 95% CI, 0.54-0.74), corresponding to a moderate predictive ability. Conclusions Postoperative serum levels of tau and GFAP were significantly elevated in cardiac surgery patients with POCD at discharge, however, the biomarkers achieved only modest predictive abilities for POCD at discharge. Postoperative levels of NSE were not associated with POCD at discharge.

OBJECTIVES There are limited data on perioperative left ventricular strain. The authors aimed to describe the entire perioperative course of two-dimensional left ventricular global longitudinal strain in patients undergoing coronary artery bypass graft (CABG) surgery and compare to common parameters of LV function assessment. DESIGN Prospective observational study. SETTING Single university hospital. PARTICIPANTS Forty patients scheduled for isolated on-pump CABG surgery with preserved left and right ventricular function with an unremarkable, complication-free perioperative course. INTERVENTIONS Two-dimensional strain analysis and standard echocardiographic assessment of left ventricular function were performed pre- (T1) and postoperatively (T4) by transthoracic echocardiography (TTE) and intraoperatively pre- (T2) and poststernotomy (T3) by transesophageal echocardiography (TEE). Echocardiography was performed under stable hemodynamics and predefined fluid management, in sinus rhythm without any vasoactive support. MEASUREMENTS AND MAIN RESULTS Analysis of two-dimensional LV global longitudinal strain (2D-LV GLS) was performed using Tomtec 2D Cardiac Performance Analysis software. Philips QLAB 10.8 was used to analyze left ventricular ejection fraction (LV EF) and tissue velocity of the lateral mitral annulus (LV S ). There were no significant differences (median with interquartile range [IQR]) after induction of anesthesia in values of LV EF and 2D-LV GLS (T1 v T2; 59% [IQR, 52 to 64] v 56% [IQR, 51.75 to 63] and -15.2 [IQR, -18.05 to -13.08] v -15.6 [IQR, -17.65 to -13.88]; both not significant [ns]), while LV S´ declined (T1 v T2, 7 cm/s [IQR, 5.25 to 8] v 5.25 cm/s [IQR, 4.6 to 6.83]; p < 0.001). Bland-Altman analysis for this comparison of 2D-LV GLS (T1 v T2) showed that bias was not significant between both techniques; however, there were limits of agreement. After sternotomy (T2 v T3) neither LV EF nor 2D-LV GLS or LV S´ declined. 2D-LV GLS deteriorated significantly after CABG (T1 v T4; -15.2 [IQR, -18.05 to -13.08] v -11.3 [IQR, -15.8 to -9.78]; p < 0.001). In contrast, LV EF and LV S´ did not change significantly in the perioperative interval (T1 v T4; 59% [IQR, 52 to 64] v 56% [IQR, 51.5 to 64.25] and 7 cm/s [IQR, 5.25 to 8] v 7 cm/s [IQR, 6 to 8]; both ns). CONCLUSION Values of 2D-LV GLS did not differ in awake, spontaneously breathing patients assessed by TTE and in anesthetized and ventilated patients with stable hemodynamics measured by TEE. 2D-LV GLS did not change after sternotomy; however, it declined significantly after on-pump CABG, while LV EF and LV S´ remained unchanged.

OBJECTIVES The aim of this study was to re-investigate the incidence, risk factors, and outcomes of postoperative diaphragmatic dysfunction (DD) with actual cardiac surgery procedures. DESIGN Single-center, retrospective, observational study based on a prospectively collected database. SETTING Tertiary care cardiac surgery center. PARTICIPANTS Patients who underwent cardiac surgery between January 2016 and September 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The DD group included patients with clinically perceptible diaphragmatic paralysis, which was confirmed by chest ultrasound (amplitude of the diaphragm movement in time-motion mode at rest, after a sniff test). The primary endpoint was the incidence of DD. Among 3,577 patients included, the authors found 272 cases of DD (7.6%). Individuals with DD had more arterial hypertension (64.3% v 52.6%; p < 0.0001), higher body mass index (BMI) (28 [25-30] kg/m2v 26 [24-29] kg/m2; p < 0.0002), and higher incidence of coronary bypass grafting (CABG) (58.8% v 46.6%; p = 0.0001). DD was associated with more postoperative pneumonia (23.9% v 8.7%; p < 0.0001), reintubation (8.8% v 2.9%; p < 0.0001), tracheotomy (3.3% v 0.3%; p < 0.0001), noninvasive ventilation (45.6% v 5.4%; p < 0.0001), duration of mechanical ventilation (five [four-11] hours v four [three-six] hours; p < 0.0001), and intensive care unit and hospital stays (14 [11-17] days v 13 [11-16] days; p < 0.0001). In multivariate analysis, DD was associated with CABG (odds ratio [OR] 1.9 [1.5-2.6]; p = 0.0001), arterial hypertension (OR 1.4 [1.1-1.9]; p = 0.008), and BMI (OR per point 1.04 [1.01-1.07] kg/m2; p = 0.003). CONCLUSIONS The incidence of symptomatic DD after cardiac surgery was 7.6%, leading to respiratory complications and increased ICU stay. CABG was the principal factor associated with DD.

Objective: Combined cardiothoracic surgery and liver transplantation (cCSLT) recently increasingly has been used. Despite that, liver transplant immediately after cardiothoracic surgery has not been well-characterized. The authors aimed to compare perioperative management and postoperative outcomes between patients undergoing cCSLT and isolated liver transplantation (iLT). Design: A retrospective study. Setting: University tertiary medical center. Participants: Twenty-five cCSLT patients and 1091 iLT patients at a single institution from 2010 to 2017. Interventions: Twenty-five cCSLT patients were compared with 100 randomly selected and 100 propensity-matched iLT patients. Measurements and Main Results: All cCSLT patients underwent comprehensive preoperative evaluation by a multidisciplinary team. Of 25 cardiothoracic surgeries, heart transplant (n = 9) was most common, followed by coronary artery bypass grafting (n = 5) and lung transplant (n = 3). Intraoperative management of cCSLT was provided by 2 separate teams, one for cardiothoracic surgery and one for liver transplantation. Patients undergoing cCSLT often required cardiopulmonary bypass, an intra-aortic balloon pump, extracorporeal membrane oxygenation, or cardiac pharmacologic therapies and, additionally, needed more interventions including antifibrinolytic administration, venovenous bypass, massive blood transfusion, and platelet transfusions compared with iLT patients. Ninety-day survival rates were similar in the cCSLT (100%) and iLT groups (random iLT 87% and matched iLT 93%, log-rank test p = 0.089). Conclusions: Despite having end-stage liver disease and advanced cardiothoracic disorders and experiencing a complex intraoperative course, cCSLT patients had comparable 90-day survival to iLT patients. Comprehensive planning before transplant, optimal patient/donor selection, the multiple-team model, and meticulous intraoperative management are critical to the success of cCSLT.

Objective Regional anesthesia techniques are gaining traction in cardiac surgery. The aim of this study was to compare the analgesic efficacy of erector spinae plane block catheters (ESPBC), serratus anterior plane block catheters (SAPBC), and paravertebral single-shot block (PVB) versus no block after robotic minimally invasive direct coronary artery bypass (MIDCAB). Design This was a retrospective observational study of routinely recorded data. Setting The study was performed at a single healthcare system. Participants All patients underwent robotic MIDCAB. Intervention Data were analyzed from 346 patients during a 53-month period. The clinical data warehouse was queried for all robotic MIDCAB surgeries. Variables abstracted included type of nerve block, age, sex, use of adjuncts, Society of Thoracic Surgeons predicted short length of stay (PSLOS), total opioid consumption during the 72 hours after surgery, and postoperative hospital length of stay (LOS). The primary outcome was total oral morphine milligram equivalents (MME) consumed during the first 72 hours after surgery. The secondary outcome was hospital LOS. Measurements and Main Results In a model adjusting for PSLOS, the authors did not observe an association between ESPBC and the reduction of total administered oral MME within 72 hours after surgery. There was no significant difference in MME when comparing patients who received PVB to patients with ESPBC. Older age and female sex were associated with significantly lower MME. Patients who received ESPBC had a significantly shorter hospital LOS than patients with SAPBC. Conclusions These findings suggested that postoperative pain after MIDCAB surgery might not be completely covered by ESPBC. Prospective studies are needed to further elucidate the value of this technique for robotic MIDCAB.

Objectives Few data exist on perioperative three-dimensional–derived right ventricular strain. The authors aimed to describe the perioperative course of three-dimensional–derived right ventricular strain in coronary artery bypass graft (CABG) surgery patients. Design Prospective, observational, pilot trial. Setting Single university hospital. Participants: The study comprised 40 patients with preserved left ventricular and right ventricular (RV) function undergoing isolated on-pump CABG surgery. Interventions: Three-dimensional strain analysis and standard echocardiographic evaluation of RV function were performed preoperatively (T1) and postoperatively (T4) with transthoracic echocardiography (TTE) and intraoperatively before sternotomy (T2) and after sternotomy (T3) with transesophageal echocardiography (TEE). All echocardiographic measurements were performed under stable hemodynamic conditions and predefined fluid management without any vasoactive support. Measurements and Main Results The measurements of three-dimensional–derived RV free-wall strain (3D-RV FWS) and RV ejection fraction were performed using TomTec 4D RV-Function 2.0 software. Philips QLAB 10.8 was used to analyze tissue velocity of the tricuspid annulus, tricuspid annular systolic excursion, and RV fractional area change. There were no significant differences (median [interquartile range {IQR}]) between preoperative TTE and intraoperative TEE measurements for 3D-RV FWS (T1 v T2: –22.35 [IQR –17.70 to –27.22] v –24.35 [IQR –20.63 to –29.88]; not significant). 3D-RV FWS remained unchanged after sternotomy (T2 v T3: –24.35 [IQR –20.63 to –29.88] v –23.75 [IQR –20.25 to –29.28]; not significant) but deteriorated significantly after CABG (T1 v T4: –22.35 [IQR –17.70 to –27.22] v –18.5 [IQR –16.90 to –21.65]; p = 0.004). Conclusion In patients undergoing on-pump CABG, 3D-RV FWS values for awake, spontaneously breathing patients measured with TTE and values assessed in patients under general anesthesia with TEE did not significantly differ. Three-dimensional RV FWS did not change after sternotomy but deteriorated after on-pump CABG.

Objective: To investigate the perioperative management of patients with hemophilia A (HA) who undergo cardiac surgery. Design Retrospective analysis of the published literature. Setting University hospital. Participants HA patients undergoing cardiac surgery. Interventions The PubMed, Embase, Web of Science Core Collection, CNKI, VIP, and WANFANG databases were searched with the terms “hemophilia A,” “cardiac surgery,” “cardiopulmonary bypass,” “coronary artery bypass graft,” “valve disease,” and “congenital heart disease” to identify relevant articles. Data regarding patient characteristics, perioperative management protocols, and clinical outcomes were extracted and analyzed. Measurements and Main Results Fifty articles, with 72 patients aging from 12 days to 80 years, were included. The analyzed population consisted of 36 (50%) mild HA, 10 (14%) moderate HA, and 25 (35%) severe HA patients. Factor VIII inhibitors were detected in 7 cases. Surgical procedures included 27 coronary artery bypass grafting procedures, 15 valve surgeries, 8 combined coronary artery bypass grafting with valve surgery procedures (1 with left ventricular assist device), 1 ventricular aneurysm resection with valve surgery, 11 corrections of congenital heart disease, 7 adult aortic surgeries, 3 heart transplantations, and 1 repair of heart injury. Factor VIII concentrates were used as a substitution therapy to ensure normalization of perioperative coagulation function. Although an uneventful clinical outcome was achieved in the majority of cases, 20% of patients developed complications with different severities. Conclusions Execution of a perioperative management strategy with a multidisciplinary approach, a thorough factor replacement protocol, and careful monitoring of factor levels facilitate an optimal outcome for HA patients undergoing cardiac surgery.

To identify and quantify the predictors of intraoperative transesophageal echocardiography (TEE) use among the patients undergoing cardiac valve or isolated coronary artery bypass graft (CABG) surgery.An observational cohort study.This study used the Centers for Medicare and Medicaid Services administrative claims dataset of the beneficiaries undergoing valve or isolated CABG surgery between 2013 to 2015.Adults aged ≥65 years of age undergoing cardiac valve or isolated CABG surgery.Generalized linear mixed-model (GLMM) analyses were used to examine the relationship between the TEE and patient characteristics, hospital factors, and staffing differences, while accounting for clustering within hospitals. The proportion of variation in TEE use attributable to patient-level characteristics was quantified using odds ratios. Hospital-level factors and staffing differences were quantified using the median odds ratios (MOR) and interval odds ratios (IOR).Among 261,860 patients (123,702 valve procedures and 138,158 isolated CABG), the GLMM analysis demonstrated that the strongest predictor for intraoperative TEE use was the hospital where the surgery occurred (MOR for TEE of 2.57 in valve and 4.16 in isolated CABG). The TEE staffing variable reduced the previously unexplained across-hospital variability by 9% in valve and 21% in isolated CABG, and hospitals with anesthesiologist TEE staffing (versus mixed) were more likely to use TEE in both valve and CABG (MOR for TEE of 1.21 in valve and 1.84 in isolated CABG).Hospital practice was the strongest predictor for TEE use overall. In isolated CABG surgery, hospitals with anesthesiologist TEE staffing were a primary predictor for TEE use.

The aim was to evaluate the effect of music on preventing delirium after coronary artery bypass grafting, to analyze vital signs and blood gas parameters, and to determine risk factors affecting delirium.A randomized clinical trial.A single-center, tertiary hospital.In total, 200 patients who underwent coronary artery bypass grafting surgery from April 2020 to April 2021.A one-hour session of new-age music was administered twice a day postoperatively for 7 days using a headphone. Delirium was assessed using the Confusion Assessment Method for the Intensive Care Unit before and after each session. Vital signs and blood gas parameters were compared to evaluate the effect of music. All assessments were conducted blindly by a different researcher.Twelve participants who were delirium-positive were in the control group, and there were 3 in the case group, which suggested a statistically significant effect of music in preventing delirium (p = 0.016). The mean age of patients was 64.7 ± 7.9 years old in the control group and 62.2 ± 7.5 years old in the case group. There was a significant difference among the control and case groups in terms of the surgery time; surgery time in the control group was significantly lower than in the case group (242.4 ± 42.3 v 261.6 ± 48.9, respectively; p = 0.030.05). Blood pressure and heart rate in the case group were lower, similar to the respiratory rate and venous blood gas parameters; Blood pressure differences were not statistically significant (p0.05); CONCLUSION: Relaxation music, including bird, water, and wind, significantly prevents delirium after coronary artery bypass grafting.

Expedited discharge after coronary artery bypass grafting (CABG) has been postulated as a possible solution for reducing hospitalization costs. This study aimed to evaluate the impact of expedited postoperative discharge on readmissions and costs in patients undergoing isolated CABG.Adults (≥18 years) who underwent isolated CABG were identified using the 2016-to-2019 Nationwide Readmission Database. Patients were classified as expedited or routine, with expedited patients being discharged on or before postoperative day 4. Those who experienced perioperative complications were excluded.The Nationwide Readmissions Database.Patients ≥18 years old who underwent isolated CABG.Of an estimated 187,591 patients meeting study criteria, 37.2% (n = 69,861) experienced expedited discharge. Expedited patients experienced lower index hospitalization costs ($28,543 v $34,114, p0.001), and were less likely to experience 30-day nonelective readmission (4.6% v 7.3%, p0.001) and 90-day nonelective readmission (5.6% v 8.7%, p0.001). After adjustment, expedited discharge remained independently associated with reduced odds of both 30-day (adjusted odds ratio [AOR]: 0.78, 95% CI: 0.71-0.85) and 90-day (AOR: 0.80, 95% CI: 0.74-0.87) nonelective readmission. In addition, expedited discharge was associated with an incremental decrease in index hospitalization costs (β: -5,661, 95% CI: -5,894 to -5,429).Expedited discharge immensely decreases costs of care for patients undergoing isolated CABG, as well as readmission risks. Expedited discharge may be considered a strategy to both improve postoperative patient care and reduce hospitalization costs within the United States healthcare system.

Objectives: To investigate the association of adenosine diphosphate (ADP)–induced platelet maximum amplitude (MAADP) with postoperative bleeding and blood product transfusions in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). Design: This single-center observational study recruited 200 patients who underwent elective, first-time, isolated CABG with CPB. A rapid thromboelastography with platelet mapping test was conducted for all patients before the surgery. Patients were categorized by the preoperative MAADP into ≤50 mm (MAADP ≤50 group [n = 87]) and MAADP >50 mm (MAADP >50 group [n = 113]). The primary outcome was postoperative bleeding at 6 and 24 hours as measured by chest tube drainage volume. The perioperative blood product transfusions, postoperative complications, postoperative time course, and in-hospital mortality also were evaluated. Setting: University hospital. Participants: Adult patients scheduled to undergo isolated primary CABG with CPB. Interventions: None. Measurements and Main Results: The study included 200 patients who underwent CABG with CPB. MAADP was >50 mm in 113 (56.5%) patients (MAADP >50 group). Compared with the MAADP >50 group, the postoperative chest tube drainage volume at 6 and 24 hours was significantly greater in the patients with MAADP ≤50 mm (476.90 ± 156.36 mL v 403.36 ± 133.24 mL; p 50 mm. The durations of intensive care unit stay and length of postoperative hospital stay were markedly longer in the MAADP ≤50 group than in the MAADP >50 group (p = 0.001 and p = 0.005; respectively). There were no significant differences in adverse outcomes between the 2 groups except for the postoperative atrial fibrillation, which occurred more in the MAADP ≤50 group than in the MAADP >50 group (8.05% v 1.77%; p = 0.043). MAADP (area under the receiver operating characteristic curve of 0.767; p Conclusions: Preoperative MAADP may play a potential role in the prediction of postoperative bleeding and allogeneic blood transfusions and guide clinicians in perioperative management of patients undergoing CABG with CPB.

Objective The aim of this study was to compare the mutual interchangeability of 4 cardiac output measuring devices by comparing their accuracy, precision, and trending ability. Design A single-center prospective observational study. Design Nonuniversity teaching hospital, single center. Participants Forty-four consecutive patients scheduled for elective, nonemergent coronary artery bypass grafting (CABG). Interventions The cardiac output was measured for each participant using 4 methods: intermittent thermodilution via pulmonary artery catheter (ITD-PAC), Endotracheal Cardiac Output Monitor (ECOM), FloTrac/Vigileo System (FLOTRAC), and 3-dimensional transesophageal echocardiography (3D-TEE). Measurements and Main Results Measurements were performed simultaneously at 5 time points: presternotomy, poststernotomy, before cardiopulmonary bypass, after cardiopulmonary bypass, and after sternal closure. A series of statistical and comparison analyses including ANOVA, Pearson correlation, Bland-Altman plots, quadrant plots, and polar plots were performed, and inherent precision for each method and percent errors for mutual interchangeability were calculated. For the 6 two-by-two comparisons of the methods, the Pearson correlation coefficients (r), the percentage errors (% error), and concordance ratios (CR) were as follows: ECOM_versus_ITD-PAC (r = 0.611, % error = 53%, CR = 75%); FLOTRAC_versus_ITD-PAC (r = 0.676, % error = 49%, CR = 77%); 3D-TEE versus ITD-PAC (r = 0.538, % error = 64%, CR = 67%); FLOTRAC_versus_ECOM (r = 0.627, % error = 51%, CR = 75%); 3D-TEE_versus ECOM (r = 0.423, % error = 70%, CR = 60%), and 3D-TEE_versus_FLOTRAC (r = 0.602, % error = 59%, CR = 61%). Conclusions Based on the recommended statistical measures of interchangeability, ECOM, FLOTRAC, and 3D-TEE are not interchangeable with each other or to the reference standard invasive ITD-PAC method in patients undergoing nonemergent cardiac bypass surgery. Despite the negative result in this study and the majority of previous studies, these less-invasive methods of CO have continued to be used in the hemodynamic management of patients. Each device has its own distinct technical features and inherent limitations; it is clear that no single device can be used universally for all patients. Therefore, different methods or devices should be chosen based on individual patient conditions, including the degree of invasiveness, measurement performance, and the ability to provide real-time, continuous CO readings.

Objective The authors aimed to investigate if the anesthetic technique was associated with 3-year all-cause mortality after isolated coronary artery bypass grafting (CABG). Design Population-based cohort study. Setting Cohort data obtained from the National Health Insurance Service database in South Korea. Participants All adult patients diagnosed with ischemic heart disease who underwent isolated CABG between January 2012 and December 2015. Exposures The authors divided the cohort into the following 2 groups: the total intravenous anesthesia group using propofol (TIVA group) and the volatile anesthesia group. Measurements and Main Results The primary study endpoint was 3-year all-cause mortality. The authors enrolled 10,440 patients from 91 hospitals; among them, 3,967 patients were in the TIVA group and 6,473 were in the volatile anesthesia group. After propensity score matching, the authors included 5,656 patients (2,828 patients per group) in the final analysis. The 3-year all-cause mortality rates in the TIVA and volatile anesthesia groups were 15.3% (434/2,828) and 18.3% (518/2,828), respectively. The risk of 3-year all-cause mortality was 16% lower in the TIVA group than in the volatile anesthesia group (hazard ratio: 0.84, 95% confidence interval: 0.75-0.94; p = 0.002). Similar results were observed for 30-day, 90-day, and 1-year all-cause mortality after CABG. Conclusion Compared with volatile anesthesia, propofol-based TIVA was associated with decreased 3-year all-cause mortality in patients undergoing CABG. This was the first study to suggest that TIVA might be associated with an increase in survival at 3-year follow-up after CABG, and further studies are needed to confirm the optimal anesthetic choice for CABG.

The authors aimed to adapt a practice advisory for the prevention of atrial fibrillation after cardiac surgery (AFACS) recently published in this journal into the authors' local perioperative protocols, implementing the recommendations, with a focus on early postoperative (re)introduction of β-blockers and overcoming frequent guideline implementation barriers.Development of a prevention care bundle and repeated audit after a model of improvement approach with retrospective analysis.Single center (tertiary academic hospital).A total of 384 patients in 2 cohorts of consecutive patients undergoing open cardiac surgery before and after hospital-wide implementation of a care bundle.After auditing the standard of care in the authors' center, an AFACS prevention care bundle was designed and implemented, consisting of a graphic tool with 5 pillars based on current evidence for the early postoperative phase. Multidisciplinary teaching and training of staff were delivered, and a second audit was conducted after the implementation period.Significantly more patients received postoperative β-blockers after care bundle implementation (82.7% pre- v 91.3% post-bundle, p = 0.019), with a higher proportion on day 1 (36.7% pre- v 67% post-bundle, p0.001), indicating a successful uptake. The incidence of AFACS was significantly reduced from 35.4% to 23.3% (p = 0.009), with a particularly marked reduction in the age group 65- to 75- years and for isolated aortic valve and coronary artery bypass graft surgery.An AFACS prevention care bundle improved adherence to current guidelines with regard to early β-blocker administration and significantly reduced the incidence of atrial fibrillation after cardiac surgery.

Patient blood management (PBM) is increasingly introduced into clinical practice. Minimizing effects on transfusion have been proven, but relevance for clinical outcome has been sparsely examined. In regard to this, the authors analyzed the impact of introducing intraoperative PBM to cardiac surgery.Retrospective case-control study.Single center.A total of 3,170 patients who underwent either coronary artery bypass grafting, isolated aortic valve replacement, or a combined procedure at the authors' institution between January 1, 2007, and December 31, 2015.In 2013, an intraoperative PBM service was established offering therapy recommendations on the basis of real-time laboratory monitoring. Comparisons to conventional coagulation management were adjusted for optimization of general, surgical, and perioperative care standards by interrupted time-series analysis and risk-dependent confounding by propensity- score matching.Primary study endpoints were in-hospital mortality and morbidity. Morbidity was defined as clinically relevant prolongation of hospital stay, which was related to accumulation of postoperative complications. Transfusion requirements, bleeding, and thromboembolic complications were not treated as primary endpoints, but were also explored. The recommendations on the basis of real-time laboratory monitoring were adopted by the operative team in 72% of patients. Intraoperative PBM was associated independently with a reduction of morbidity (8.3% v 6.3%, p = 0.034), whereas in-hospitalmortality (3.0% v 2.6%, p = 0.521) remained unaffected. The need for red blood cell transfusion decreased (71.1% v 65.0%, p0.001), as did bleeding complications requiring surgical re-exploration (3.5% v 1.8%, p = 0.004). At the same time, stroke increased by statistical trend (1.0% v 1.9%, p = 0.038; after correction for imbalanced type of surgical procedure p = 0.085).Real-time laboratory recommendations achieved a high acceptance rate early after initiation. Improvement of clinical outcome by intraoperative PBM adds to the optimized surgical care. However, the corridor between hemostatic optimization and thromboembolic risk may be narrow.

To compare the changes in thoracic fluid content, PaOProspective observational study.Tertiary-care cardiac center.Over an 18-month period, from December 2019 to May 2021, 111 patients who underwent CAB grafting were enrolled. Group I constituted OPCAB patients and Group II the ONCAB patients.After induction, the authors measured thoracic fluid content (TFC), pulmonary compliance, airway pressures, and the PaOAt TThe change in TFC was greater in the ONCAB group, despite the fact that the fluid balance was higher in the OPCAB group. A higher TFC in ONCAB led to lower PaO

Coronary artery bypass grafting represents one of the most commonly performed cardiac surgeries worldwide. Recently, interest has increased in providing patients with a less invasive approach to cardiac surgery, such as thoracotomy and endoscopic techniques using robotic technology as an alternative to traditional sternotomy. As the population gets older, the need for additional methods to provide care for sick patients will continue to expand. These advancements will further allow physicians to provide cardiac surgical procedures with less pain and faster recovery for patients.

Postoperative atrial fibrillation (POAF) after cardiac surgery remains a highly prevalent and costly condition that negatively impacts patient quality of life and survival. Numerous retrospective studies, meta-analysis, and review papers have been reported identifying POAF risk based on patients' risk factors and clinical biomarkers. In this narrative review, the authors report significant variations among selected pre- and perioperative biomarkers used to predict POAF incidence in patients without a history of atrial fibrillation (AF). POAF prediction based on B-type natriuretic peptide, N-terminal pro B-type natriuretic peptide, C-reactive protein, interleukin-6, creatinine, and plasminogen activator inhibitor-1 differs significantly among different studies, thereby limiting their clinical utility to predict POAF risk with high accuracy. Conversely, soluble vascular endothelial cells adhesion molecule-1, soluble CD40 ligand, Galectin-3, and aldosterone show promise for better POAF prediction. However, the current datasets for these selected biomarkers are not of sufficient size to validate the broad clinical application specifically for patients with no prior history of AF.

Objective: Primary outcome was the risk for infections after cell salvage in cardiac surgery. Design: Data of a randomized controlled trial on cell salvage and filter use (ISRCTN58333401). Setting: Six cardiac surgery centers in the Netherlands. Participants: All 716 patients undergoing elective coronary artery bypass grafting, valve surgery, or combined procedures over a 4-year period who completed the trial. Interventions: Postoperative infection data were assessed according to Centre of Disease Control and Prevention/National Healthcare Safety Network surveillance definitions. Measurements and Main Results: Fifty-eight (15.9%) patients with cell salvage had infections, compared with 46 (13.1%) control patients. Mediation analysis was performed to estimate the direct effect of cell salvage on infections (OR 2.291 [1.177;4.460], p = 0.015) and the indirect effects of allogeneic transfusion and processed cell salvage blood on infections. Correction for confounders, including age, seks and body mass index was performed. Allogeneic transfusion had a direct effect on infections (OR = 2.082 [1.133;3.828], p = 0.018), but processed cell salvage blood did not (OR = 0.999 [0.999; 1.001], p = 0.089). There was a positive direct effect of cell salvage on allogeneic transfusion (OR = 0.275 [0.176;0.432], p < 0.001), but a negative direct effect of processed cell salvage blood (1.001 [1.001;1.002], p < 0.001) on allogeneic transfusion. Finally, there was a positive direct effect of cell salvage on the amount of processed blood. Conclusions: Cell salvage was directly associated with higher infection rates, but this direct effect was almost completely eliminated by its indirect protective effect through reduced allogeneic blood transfusion.

To test the association between transesophageal echocardiography (TEE) and incidence of acute kidney injury and length of hospitalization among United States adults undergoing isolated coronary artery bypass graft (CABG) surgery.This was an observational, retrospective cohort analysis.This study used a multicenter claims dataset from a commercially insured population undergoing CABG surgery in the United States between 2004 and 2016.Adults aged 18 years or older with continuous insurance enrollment and an absence of renal-related diagnoses before the index CABG surgery.Receipt of TEE within 1 calendar day of the index CABG surgery date.Of 51,487 CABG surgeries, 5,361 (10.4%; [95% confidence interval [CI]: 10.1-10.7%]) developed acute kidney injury and the mean length of hospitalization was 8.8 days (95% CI: 8.7-8.8). The TEE group demonstrated a greater absolute risk difference (RD) for acute kidney injury by multiple linear regression, overall, (RD=+1.0; [95% CI: 0.4-1.5%]; p0.001) and among a low-risk subgroup (RD=+1.0; [95% CI: 0.4-1.6; p = 0.002), but not by instrumental variable analysis (RD=+0.9 [95% CI: -1.1 to 2.9%]; p = 0.362). The TEE group demonstrated a longer length of hospitalization by multiple linear regression, overall (+2.0%; [95% CI: 1.1-2.9%]; p0.001), among a low-risk subgroup (+2.2%; [95% CI: 1.2-3.2%]; p0.001), and by instrumental variable analysis (+10.3%; [95% CI: 7.0-13.7%]; p0.001).TEE monitoring in CABG surgery was not associated with a lower incidence of acute kidney injury or decreased length of hospitalization. These findings highlight the importance of additional work to study the clinical effectiveness of TEE in CABG surgery.

This highlights in our specialty for 2019 begin with the ongoing major developments in transcatheter valve interventions. Thereafter, the advances in left ventricular assist devices are reviewed. The recent focus on conduit selection and robotic options in coronary artery bypass surgery are then explored. Finally, this special articles closes with a discussion of pulmonary hypertension in noncardiac surgery, anesthetic technique in cardiac surgery, as well as postoperative pneumonia and its outcome consequences.

Augmentation of coronary artery flow by surgical grafting increases coronary sinus blood flow (CSBF), which can be quantified on transesophageal echocardiography (TEE). However, transit time flowmetry (TTF) technology remains the most used intraoperative technique for coronary artery graft assessment. The purpose of the present pilot study was to evaluate the predictive value of TEE-based CSBF estimation for identifying favorable TTF graft measurements.Prospective observational study.Single university hospital.Forty patients undergoing triple vessel coronary artery bypass grafting.CSBF was assessed on TEE examination before and after revascularization, estimating the percentage increase in CSBF (∆CSBF). Postoperative TTF graft measurements were averaged to compute mean diastolic filling (DF) and pulsatility index (PI). Subjects were grouped based on favorable (PI ≤ 3, DF ≥ 50%) and unfavorable (PI3, DF50%) parameters. The group with PI ≤ 3 (n = 32) had significantly higher ∆CSBF compared with the group with PI3 (n = 8) (38.22% ± 12.05%, 13.75% ± 3.37%, p0.001). ∆CSBF was higher in the DF ≥ 50% group (n = 35) (36.40 ± 12.99) in contrast to DF50% group (n = 5) (11.80 ± 2.59%). A strong negative and significantly positive correlation was observed between ∆CSBF with PI, DF (r = -0.903, 0.571, respectively, p0.001). A ∆CSBF ≥15.5% was found to predict a mean PI ≤ 3 and DF ≥ 50% with sensitivity and specificity of 100% and 62.5% for PI and 100% and 100% for DF. A ∆CSBF ≥19% demonstrated a sensitivity and specificity of 100% and 100%, 100% and 91.4% for prediction of PI ≤ 3 and DF ≥ 50%, respectively.TEE-based demonstration of an augmented CSBF can ensure favorable TTF graft parameters, guiding the adequacy of surgical revascularization.

Objective Investigate important clinical and operative variables associated with increases in cardiac troponin T (cTnT) as indicators of myocardial injury after coronary artery bypass grafting (CABG). Design Prospective cohort study. Setting Single university hospital. Participants The study comprised 626 patients undergoing isolated CABG from April 2008 through April 2010 with a validation cohort (n = 686) from 2015-2017. Interventions None. Measurements and Main Results Perioperative variables were registered prospectively. The extent of diffuse coronary atherosclerosis and significant stenoses were assessed with preoperative coronary angiography. Mixed model analysis was used to construct a statistical model explaining the course of cTnT concentrations. The model was adjusted for preoperative and intraoperative/postoperative myocardial infarction (MI) for independent assessment of additional variables. Clinical factors associated with increased cTnT concentrations during and after CABG were longer duration of cardiopulmonary bypass (p < 0.001), higher preoperative creatinine (p < 0.001), New York Heart Association functional classification IV (p = 0.006), reduced LVEF (p = 0.034), higher preoperative C-reactive protein (p = 0.049), and intraoperative/postoperative MI (p < 0.001). Factors associated with decreasing cTnT concentrations during CABG were higher BSA (p < 0.001) and a recent preoperative MI (p < 0.001). The extent of diffuse coronary atherosclerosis and significant stenoses were not associated with changes in cTnT (p = 0.35). Results were similar in the validation cohort. Conclusions Left ventricular ejection fraction, New York Heart Association classification, kidney function, inflammation status, duration of cardiopulmonary bypass, body surface area, and preoperative MI were associated with the cTnT rise-and-fall pattern related to myocardial injury after CABG. Information regarding these variables may be valuable when using cTnT in the diagnostic workup of postoperative MI. (C) 2019 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/)Journal of Cardiothoracic and Vascular Anesthesia 33 (2019) 3309 3319Contents lists available atScienceDirectJournal of Cardiothoracic and Vascular Anesthesiajournal homepage:www.jcvaonline.com

Myocardial management during on-pump coronary artery bypass grafting (CABG) surgery includes aortic cross-clamping followed by fibrillation (XCF) and aortic cross-clamping followed by diastolic cardioplegia (cardioplegia). The authors wished to compare in-hospital and survival outcomes between these procedures.A retrospective observational study utilizing propensity matching.Tertiary Referral Centre for Heart Surgery.A total of 8,875 consecutive patients undergoing CABG surgery between August 1999 and February 2018.After 1:1 matching, the authors had 3,340 patients in the cardioplegia group and 3,340 in the XCF group.Baseline characteristics were not significant between the matched cardioplegia and XCF groups. The XCF group had shorter pump times (61.8 minutes +/-26.8 v 74.7 minutes +/-29.5, p0.0001) and shorter cross-clamp times (27.80 minutes +/-10.5 v 44.44 minutes +/-18.0, p0.0001) compared with the cardioplegia group despite a similar median number of distal anastomoses (3 v 3, p = 0.08). After surgery, atrial arrhythmias (32% v 36%, p = 0.01) and inotropic requirement (25% v 28%, p = 0.006) were less in the XCF group compared with the cardioplegia group, respectively. Other postoperative outcomes (such as mortality and cerebrovascular events) were not statistically different. There was a mean survival advantage in using cardioplegia compared with XCF (15.4 years versus 14.7 years, log-rank, p = 0.014; 10-year survival 64% v 61% and 18-year survival 38% v 34%).This is the largest analysis of XCF. XCF does not adversely affect in-hospital outcomes. Long-term results demonstrate cardioplegic arrest may convey a survival advantage that would preclude routine XCF in the modern era.

Predictors of operative outcome in patients with severely depressed left ventricular ejection fraction (LVEF) undergoing coronary artery bypass grafting (CABG) remain poorly defined. This study aims to identify preoperative variables that are associated with increased postoperative length of hospital stay or operative mortality in this patient population.Retrospective study.Single tertiary care university hospital.Patients undergoing isolated CABG between January 2012 and March 2017 with an LVEF ≤ 25%.Isolated CABG.Primary endpoint was a composite of prolonged length of stay, defined as postoperative length of stay7 days or operative mortality. Of the 201 patients, 99 (49.3%) met the primary endpoint. Patient comorbidities, clinical presentation, presence of Q-waves on electrocardiogram, and echocardiographic parameters including ventricular dimensions and right heart dysfunction were not associated with the primary endpoint. On multivariable analysis, patients who were not on preoperative beta-blockers, patients with preoperative albumin of3.5 g/dL, and higher Society of Thoracic Surgeons Predicted Risk of Mortality score were associated with increased prolonged length of stay or death.More than half of patients with severely depressed LVEF undergoing isolated CABG are able to be discharged within 7 days postoperatively. The absence of preoperative beta-blockers, low preoperative albumin levels, and higher Society of Thoracic Surgeons Predicted Risk of Mortality score are associated with more complicated or slower postoperative recovery after CABG in this patient population.