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Background Risk factors for bleeding complications during extracorporeal life support (ECLS) indicated for cardiac support remain poorly investigated. The aim is to develop and internally validate a prediction model to calculate the risk for bleeding complications in adult patients receiving veno-arterial (V-A) ECLS. Methods Data of the Extracorporeal Life Support Organization registry of adult patients undergoing V-A ECLS between 2010 and 2020 were analyzed. The primary outcome was bleeding complications recorded during V-A ECLS. Multivariable logistic regression with backward stepwise elimination was used to develop the prediction model. Performance of the model was tested by discriminative ability and calibration with receiver operator characteristic, area under the curve, and visual inspection of the calibration plot. Internal validation was performed to detect overfitting of the model. Results In total 28 767 adult patients were included, of which 29.0% developed bleeding complications. Sex, body mass index, surgical cannulation, pre-ECLS respiratory and hemodynamic variables, pre-ECLS support and interventions, and different type of diagnosis were included in the prediction model. This prediction model showed a predictive capability with an AUC of 0.66. Conclusion The model is based on the largest cohort of V-A ECLS patients and is the best available predictive model for bleeding events given the predictors that are available in V-A ECLS compared to current literature. The model can help in identifying patients at high risk for bleeding complications and will help in developing further research and decision-making in terms of anticoagulation management. External validation is warranted to extrapolate this model in the clinical setting.

OBJECTIVES Unanticipated cancellation of a surgical procedure is a common problem, causing distress to the patient and increases in healthcare costs. However, limited evidence exists on the effects of last-minute cancellations of cardiothoracic surgical procedures in particular. The goal of this study was to gain insight into the prevalence of and the reasons for last-minute cancellations and to examine whether cancellation is associated with adverse medical outcomes. METHODS Patients who were scheduled for elective cardiothoracic surgical procedures between January 2017 and June 2019 were evaluated. The reasons for the cancellations were assigned to the categories medically related or process related. We examined the differences in patient characteristics between those designated as no cancellation, medically related cancellations and process-related cancellations. Lastly, we examined the outcomes of patients who experienced a last-minute cancellation of a scheduled operation. RESULTS A total of 2111 patients were included; of these, 301 (14.3%) had last-minute cancellations. In 78 (26%) cases, the cancellations were attributable to medical reasons (e.g. infection, comorbidities); 215 (71%) of the cancellations were process related (e.g. another patient in more urgent need of surgery, lack of staff). Almost 99% of the operations with a process-related cancellation were rescheduled compared to only 71.8% of the medically related cancelled operations (P, Unanticipated cancellation of scheduled surgery often has a negative impact on patient experience, outcomes and healthcare costs [1, 2].

Cardiac surgery on cardiopulmonary bypass (CPB) is associated with postoperative renal dysfunction, one of the most common complications of this surgical cohort. Acute kidney injury (AKI) is associated with increased short-term morbidity and mortality and has been the focus of much research. There is increasing recognition of the role of AKI as the key pathophysiological state leading to the disease entities acute and chronic kidney disease (AKD and CKD). In this narrative review, we will consider the epidemiology of renal dysfunction after cardiac surgery on CPB and the clinical manifestations across the spectrum of disease. We will discuss the transition between different states of injury and dysfunction, and, importantly, the relevance to clinicians. The specific facets of kidney injury on extracorporeal circulation will be described and the current evidence evaluated for the use of perfusion-based techniques to reduce the incidence and mitigate the complications of renal dysfunction after cardiac surgery. ispartof: PERFUSION-UK ispartof: location:England status: Published online

Background: This study aims to get an effective machine learning (ML) prediction model of new-onset postoperative atrial fibrillation (POAF) following coronary artery bypass grafting (CABG) and to highlight the most relevant clinical factors. Methods: Four ML algorithms were employed to analyze 394 patients undergoing CABG, and their performances were compared: Multivariate Adaptive Regression Spline, Neural Network, Random Forest, and Support Vector Machine. Each algorithm was applied to the training data set to choose the most important features and to build a predictive model. The better performance for each model was obtained by a hyperparameters search, and the Receiver Operating Characteristic Area Under the Curve metric was selected to choose the best model. The best instances of each model were fed with the test data set, and some metrics were generated to assess the performance of the models on the unseen data set. A traditional logistic regression was also performed to be compared with the machine learning models. Results: Random Forest model showed the best performance, and the top five predictive features included age, preoperative creatinine values, time of aortic cross-clamping, body surface area, and Logistic Euro-Score. Conclusions: The use of ML for clinical predictions requires an accurate evaluation of the models and their hyperparameters. Random Forest outperformed all other models in the clinical prediction of POAF following CABG.

Altres ajuts: acords transformatius de la UAB Altres ajuts: Swiss National Science Foundation (SNSF) [NCCR Synapsy grant: 51NF40-158776 and − 185897] Posttraumatic stress disorder (PTSD) is a highly disabling psychiatric condition that may arise after exposure to acute and severe trauma. It is a highly prevalent mental disorder worldwide, and the current treatment options for these patients remain limited due to low effectiveness. The time window right after traumatic events provides clinicians with a unique opportunity for preventive interventions against potential deleterious alterations in brain function that lead to PTSD. Some studies pointed out that PTSD patients present an abnormal function of the hypothalamic-pituitary-adrenal axis that may contribute to a vulnerability toward PTSD. Moreover, glucocorticoids have arisen as a promising option for preventing the disorder's development when administered in the aftermath of trauma. The present work compiles the recent findings of glucocorticoid administration for the prevention of a PTSD phenotype, from human studies to animal models of PTSD. Overall, glucocorticoid-based therapies for preventing PTSD demonstrated moderate evidence in terms of efficacy in both clinical and preclinical studies. Although clinical studies point out that glucocorticoids may not be effective for all patients' subpopulations, those with adequate traits might greatly benefit from them. Preclinical studies provide precise insight into the mechanisms mediating this preventive effect, showing glucocorticoid-based prevention to reduce long-lasting behavioral and neurobiological abnormalities caused by traumatic stress. However, further research is needed to delineate the precise mechanisms and the extent to which these interventions can translate into lower PTSD rates and morbidity.

Purpose of review To give an overview of cerebral monitoring techniques for surgical ICU patients. Recent findings As the burden of postsurgical neurological and neurocognitive complications becomes increasingly recognized, cerebral monitoring in the surgical ICU might gain a relevant role in detecting and possibly preventing adverse outcomes. However, identifying neurological alterations in surgical ICU patients, who are often sedated and mechanically ventilated, can be challenging. Various noninvasive and invasive techniques are available for cerebral monitoring, providing an assessment of cortical electrical activity, cerebral oxygenation, blood flow autoregulation, intracranial pressure, and cerebral metabolism. These techniques can be used for the diagnosis of subclinical seizures, the assessment of sedation depth and delirium, the detection of an impaired cerebral blood flow, and the diagnosis of neurosurgical complications. Summary Cerebral monitoring can be a valuable tool in the early detection of adverse outcomes in surgical ICU patients, but the evidence is limited, and clear clinical indications are still lacking.

Cardiogenic shock is the most frequent kind of shock in cardiac intensive care, and cardiac dysfunction and hypoxia are often seen in critically ill patients. Inadequate organ and tissue perfusion and hypoxia result in anaerobic metabolism with hyperlactatemia and oxygen debt accumulation. However, the role of accumulated oxygen debt in the course of cardiogenic shock and hypoxia has not been clearly described. Here, we first described the existence of several patterns of oxygen debt repayment in cardiogenic shock patients maintained by an extracorporeal life support system. Oxygen debt was computed from the lactate concentration at five time points, covering the first 26 h of ECLS. Patterns representing basic pathophysiological processes were independent of the cause of the primary insult. Groups of patients classified into specific patterns differed in terms of survival rate from 51.5% to only 4.6%. It is very important that the initial group not predetermine the fate of the patient and may change in the course of treatment due to 'between-cluster migration'. We believe that our finding of different patterns of oxygen debt repayment in cardiogenic shock patients may offer new insights for a more rational, goal-directed treatment of highly morbid conditions such as hypoxia and cardiogenic shock.

Objectives: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides a temporary support system for patients with cardiogenic shock refractory to conventional medical therapies. It has been reported that levosimendan may facilitate VA-ECMO weaning and improve survival. The primary objective of this review was to examine the effect of levosimendan use on VA-ECMO weaning and mortality in critically ill patients on VA-ECMO.Design: MEDLINE, EMBASE, and CENTRAL were searched. A pair of reviewers identified eligible clinical trials. Two reviewers extracted data and independently assessed the risk of bias. A random-effect model was used to combine data. The primary outcome was the success of weaning from VA-ECMO.Measurements and Main Results: Seven studies of observational design, including a total of 630 patients, were selected in the final analysis. The sample size ranged from ten-to-240 patients, with a mean age between 53 and 65 years, and more than half of them underwent cardiac surgeries. The VA-ECMO durations varied between four and 11.6 days. Overall, levosimendan use was significantly associated with successful weaning compared with control (odds ratio [OR] 2.89, 95% CI, 1.53-5.46; (poverall effect) = 0.001); I-2 = 49%). For survival, six studies (n = 617) were included in the meta-analysis involving 326 patients in the levosimendan group and 291 in the comparator group. Pooled results showed a significantly higher survival rate in the levosimendan group (OR 0.46, 95% CI, 0.30-0.71; (poverall effect) = 0.0004; I-2 = 20%).Conclusions: Levosimendan therapy was significantly associated with successful weaning and survival benefit in patients with cardiogenic or postcardiotomy shock needing VA-ECMO support for severe cardiocirculatory compromise. To date, there is limited literature and absence of evidence from randomized trials addressing the use of levosimendan in VA-ECMO weaning. This study may be considered a hypothesis-generating research for randomized controlled trials to confirm its findings. (C) 2021 The Authors. Published by Elsevier Inc.

ObjectiveThis study aimed to explore the influence of coronary artery bypass grafting (CABG) on both postoperative cognitive dysfunction and quality of life (QoL) and the association between the two patient-related outcomes.MethodsIn a prospective, observational cohort study, patients with elective, isolated CABG were included. Cognitive function was assessed using the Cogstate computerised cognitive test battery preoperatively, 3 days and 6 months after surgery. QoL was measured preoperatively and at 6 months using the RAND-36 questionnaire including the Physical Component Score (PCS) and the Mental Component Score (MCS). Regression analysis, with adjustment for confounders, was used to evaluate the association between postoperative cognitive dysfunction and QoL.ResultsA total of 142 patients were included in the study. Evidence of persistent cognitive dysfunction was observed in 33% of patients after 6 months. At 6 months, the PCS had improved in 59% and decreased in 21% of patients, and the MCS increased in 49% and decreased in 29%. Postoperative cognitive changes were not associated with QoL scores.ConclusionsPostoperative cognitive dysfunction and decreased QoL are common 6 months after surgery, although cognitive function and QoL were found to have improved in many patients at 6 months of follow-up. Impaired cognitive function is not associated with impaired QoL at 6 months.Trial registration numberNCT03774342.

Introduction Early oxygen debt repayment is predictive of successful weaning from veno-arterial extracorporeal membrane oxygenation (V-A ECMO). However, studies are limited by the patient cohort’s heterogeneity. This study aimed to understand the early state of oxygen debt repayment and its association with end-organ failure and 30-day survival using cluster analysis. Methods A retrospective, single-center study was conducted on 153V-A ECMO patients. Patients were clustered using a two-step cluster analysis based on oxygen debt and its repayment during the first 24 h of ECMO. Primary outcomes were end-organ failure and 30-day survival. Results The overall mortality was 69.3%. For cluster analysis, 137 patients were included, due to an incomplete data set. The mortality rate in this subset was 67.9%. Three clusters were generated, representing increasing levels of total oxygen debt from cluster 1 to cluster 3. Thirty-day survival between clusters was significantly different (cluster 1: 46.9%, cluster 2: 23.4%, and cluster 3: 4.8%, p = 0.001). Patients in cluster 3 showed less decrement in liver enzymes, creatinine, and urea blood levels. There were significant differences in the baseline oxygen debt and the need for continuous veno-venous hemofiltration (CVVH) between survivors and non-survivors (p Conclusions Oxygen debt repayment during the first 24 h of V-A ECMO shows to correspond with survival, where the baseline oxygen debt value and the necessity for continuous kidney replacement therapy appear to be influential.

Heart failure is associated with decreased tissue perfusion and increased venous congestion that may result in organ dysfunction. This dysfunction has been investigated extensively for many organs, but data regarding pancreatic (exocrine) dysfunction are scarce. In the present review we will discuss the available data on the mechanisms of pancreatic damage, how heart failure can lead to exocrine dysfunction, and its clinical consequences. We will show that heart failure causes significant impairment of pancreatic exocrine function, particularly in the elderly, which may exacerbate the clinical syndrome of heart failure. In addition, pancreatic exocrine insufficiency may lead to further deterioration of cardiovascular disease and heart failure, thus constituting a true vicious circle. We aim to provide insight into the pathophysiological mechanisms that constitute this reciprocal relation. Finally, novel treatment options for pancreatic dysfunction in heart failure are discussed.

Introduction: Studies have shown that a hemodynamic-guided therapy improves the post operative outcomes of high-risk patients.This study, evaluated if a short period through minimally invasive hemodynamic monitoring, pressure recording analytical method (PRAM), on admission to a post-cardiac surgery step-down unit (SDU), may identify patients at higher risk of 6-month adverse events after cardiac surgery. Methods: From December 2016-May 2017,173 patients were admitted in SDU within 24-48 hours of major cardiac surgery procedure, and submitted to clinical, laboratoristic and echocardiographic evaluation and a 1-hour PRAM recording to obtain a "biohumoral snapshot" of individual patient’s.156 173 patients (17 patients were lost at follow-up) were phone interviewed six months after surgery,to evaluate, as a composite end-point, the adverse events during follow-up. A multivariable logistic regression analysis was used to identify a model clinical-biohumoral (CBM) and clinical-biohumoral hemodynamics (CBHM). Results: No data from past clinical history and no conventional risk score (EuroScore II, STS score)independently predicted the risk of 6-month major events in our study. The risk of adverse events at six-month follow-up was directly related, in the CBM, to sustained post-operative cardiac arrhythmias, higher values of NT-proBNP and of arterial pH; inversely related to values of hs-C-reactive protein (hs-CRP) and, in the CBHM, to low values of cardiac cycle efficiency (CCE) and dP/dtmax. Conclusion: Our study although limited by its observational nature and by the limited number of patients enrolled, showed that a short period of minimally invasive hemodynamic monitoring increased the accuracy to identify patients at major risk of mid-term events after cardiac surgery.

Background:Efforts have been made to minimize transfusion of packed red blood cells in patients undergoing cardiac surgery with cardiopulmonary bypass. One method concerns retrograde autologous priming. Although the technique has been used for decades, results remain contradictory in terms of transfusion requirements.Objective:This systematic literature review aimed to summarize the evidence for the efficacy of retrograde autologous priming in terms of decreasing perioperative packed red blood cell requirements in adults.Methods:Two researchers independently searched PubMed for articles published in the past 10 years. The modified Cochrane collaboration Risk of Bias Tool and the Research Triangle Institute Item Bank were used to assess bias.Results:Eight studies were included, of which two randomized and six observational studies. Five studies, including one randomized study, report a significant decrease in packed red blood cell use in the retrograde autologous priming group compared to no retrograde autologous priming used. All studies are flawed by at least a high risk bias of bias score on one item of the bias assessment.Conclusion:Although most studies reported significantly fewer packed red blood cell transfusions in the retrograde autologous priming group, it is important to note that relatively few articles are available which are flawed by several types of bias. Prospective, randomized multi-center trials are warranted to conclude decisively on the benefits of retrograde autologous priming.

Rationale: Postoperative atrial fibrillation (POAF) is a common and troublesome complication of cardiac surgery. POAF is generally believed to occur when postoperative triggers act on a preexisting vulnerable substrate, but the underlying cellular and molecular mechanisms are largely unknown. Objective: To identify cellular POAF mechanisms in right atrial samples from patients without a history of atrial fibrillation undergoing open-heart surgery. Methods and Results: Multicellular action potentials, membrane ion-currents (perforated patch-clamp), or simultaneous membrane-current (ruptured patch-clamp) and [Ca 2+ ] i -recordings in atrial cardiomyocytes, along with protein-expression levels in tissue homogenates or cardiomyocytes, were assessed in 265 atrial samples from patients without or with POAF. No indices of electrical, profibrotic, or connexin remodeling were noted in POAF, but Ca 2+ -transient amplitude was smaller, although spontaneous sarcoplasmic reticulum (SR) Ca 2+ -release events and L-type Ca 2+ -current alternans occurred more frequently. CaMKII (Ca 2+ /calmodulin-dependent protein kinase-II) protein-expression, CaMKII-dependent phosphorylation of the cardiac RyR2 (ryanodine-receptor channel type-2), and RyR2 single-channel open-probability were significantly increased in POAF. SR Ca 2+ -content was unchanged in POAF despite greater SR Ca 2+ -leak, with a trend towards increased SR Ca 2+ -ATPase activity. Patients with POAF also showed stronger expression of activated components of the NLRP3 (NACHT, LRR, and PYD domains-containing protein-3)-inflammasome system in atrial whole-tissue homogenates and cardiomyocytes. Acute application of interleukin-1β caused NLRP3-signaling activation and CaMKII-dependent RyR2/phospholamban hyperphosphorylation in an immortalized mouse atrial cardiomyocyte cell-line (HL-1-cardiomyocytes) and enhanced spontaneous SR Ca 2+ -release events in both POAF cardiomyocytes and HL-1-cardiomyocytes. Computational modeling showed that RyR2 dysfunction and increased SR Ca 2+ -uptake are sufficient to reproduce the Ca 2+ -handling phenotype and indicated an increased risk of proarrhythmic delayed afterdepolarizations in POAF subjects in response to interleukin-1β. Conclusions: Preexisting Ca 2+ -handling abnormalities and activation of NLRP3-inflammasome/CaMKII signaling are evident in atrial cardiomyocytes from patients who subsequently develop POAF. These molecular substrates sensitize cardiomyocytes to spontaneous Ca 2+ -releases and arrhythmogenic afterdepolarizations, particularly upon exposure to inflammatory mediators. Our data reveal a potential cellular and molecular substrate for this important clinical problem.

OBJECTIVES We have developed a high-fidelity minimally invasive mitral valve surgery (MIMVS) simulator that provides a platform to train skills in an objective and reproducible manner, which has been incorporated in the European Association for Cardiothoracic Surgery (EACTS) endoscopic mitral valve repair course. The aim of the study is to provide data on the application of simulation-based training in MIMVS using an air-pilot training concept. METHODS The 2-day EACTS endoscopic mitral training course design was based on backwards chaining, pre- and post-assessment, performance feedback, hands-on training on MIMVS, theoretical content and follow-up. One hundred two participants who completed the full programme throughout 2016–2018 in the EACTS endoscopic mitral training courses were enrolled in the current study. RESULTS Of the 102 participants, 83 (83.3%) participants were staff/attending surgeons, 12 (11.8%) participants had finished residency and 5 (4.9%) participants were residents. Theoretical pre- and post-assessment showed that participants scored significantly higher on post-assessment (median score 58% vs 67%, P CONCLUSIONS The MIMVS is a valuable tool for the development and assessment of endoscopic mitral repair skills. This EACTS course provides surgeons with theoretical knowledge and necessary skills to start an endoscopic mitral valve programme successfully.

Background and Objectives While iron deficiency (ID) is the most common cause of anaemia, little is known about the prevalence and type of ID in preoperative surgical patients. The aims of the present study were to investigate the prevalence and types of ID in a large cohort of surgical patients, and how these are related to perioperative blood use after correction for confounders such as haemoglobin level.Materials and MethodsData were retrospectively extracted from electronic case records of all patients who underwent elective surgery between September 2016 and November 2017 (n = 2711). Iron parameters, haemoglobin and details of perioperative red cell transfusions were collected.ResultsOf 2711 patients, 618 (22.8%) were iron deficient (= transferrin saturation [TSAT] < 16%) preoperatively, 173 (6.4% of the cohort) had an absolute iron deficiency (AID; TSAT < 16% and ferritin < 30 mu g/L) and 445 (16.4%) had functional/mixed ID (TSAT < 16% and ferritin >= 30 mu g/L). Corrected for Hb level, iron-deficient patients received significantly more red cell units than patients without ID (p = 0.026). AID was not associated with a significantly higher incidence of transfusions (7.5% of patients transfused; p = 0.12 after correction for Hb) than patients without ID, whereas patients with functional/mixed deficiency did receive significantly more transfusions (6.1%; p = 0.021) as compared to patients without ID (1.7%).ConclusionPreoperative ID, in particular the functional/mixed type, was associated with a higher risk of receiving perioperative red cell transfusions as compared to patients without ID. Adequately treating ID might, therefore, reduce the need for perioperative red cell transfusions.

The use of wire cerclage after sternal closure is the standard method because of its rigidity and strength. Despite this, they have many disadvantages such as tissue trauma, operatorinduced failures, and the risk of infection. To avoid complications during sternotomy and promote tissue regeneration, tissue adhesives should be used in post-surgical treatment. Here, we report a highly biocompatible, biomimetic, biodegradable, antibacterial, and UV-curable polyurethane-acrylate (PU-A) tissue adhesive for sternal closure as a supportive to wire cerclage. In the study, PU-As were synthesized with variable biocompatible monomers, such as silk sericin, polyethylene glycol, dopamine, and an aliphatic isocyanate 4,4'-methylenebis(cyclohexyl isocyanate). The highest adhesion strength was found to be 4322 kPa, and the ex vivo compressive test result was determined as 715 kPa. The adhesive was determined to be highly biocompatible (on L929 cells), biodegradable, and antibacterial (on Escherichia coli, Pseudomonas aeruginosa, and Staphylococcus aureus bacteria). Finally, after opening the sternum of rats, the adhesive was applied to bond the bones and cured with UV for 5 min. According to the results, there was no visible inflammation in the adhesive groups, while some animals had high inflammation in the cyanoacrylate and wire cerclage groups. These results indicate that the adhesive may be suitable for sternal fixation by preventing the disadvantages of the steel wires and promoting tissue healing. Scientific and Technological Research Council of Turkey [116Z501]; Inonu University Research Fund [IUBAP FDP-2018-1284] ? ACKNOWLEDGMENTS This work was supported financially by the Scientific and Technological Research Council of Turkey (Project no. 116Z501) and Inonu University Research Fund (IUBAP FDP-2018-1284) . The authors acknowledge Prof. Dr. Mehmet Fethi CEYLAN for his assistance in sternal closure surgery.

Background: Inhaled nitric oxide (iNO) is a well-established off-label treatment of acute hypoxic respiratory failure and pulmonary hypertension, but high drug cost and lack of consistent proof of clinical benefit have led to restrictive expert recommendations regarding its use. Objectives: To evaluate the current practice of the use of iNO in different hospital settings at an international society level. Design & Setting: Web-based survey distributed via email to ESAIC and EACTAIC members. Methods: Survey responses are depicted as absolute frequencies and percentages that were analysed using Microsoft Excel. Results: One third of the respondents had institutional guidelines for the use of iNO. Pulmonary arterial hypertension, right ventricular failure, persistent pulmonary hypertension of the newborn and adult respiratory distress syndrome were the main indications for treatment with iNO. Prophylactic use of iNO during heart and lung transplantation or VAD implantation surgery was reported by 12-34%. The most frequently reported doses were 10-20 ppm and 20-40 ppm as initial and maximum treatment doses, respectively. Echocardiography was the most universally used form of advanced hemodynamic monitoring during treatment with iNO, followed by pulmonary artery catheterization. Half of the respondents had a fixed strategy to prevent rebound pulmonary hypertension during weaning from iNO, using phosphodiesterase inhibitors, prostacyclins or calcium channel antagonists. Conclusion: In line with the available evidence and expert recommendations, iNO remains a rescue treatment reserved for the most severe cases in highly specialized centres. The observations made in this survey should inspire future research to help better define the role of iNO, also in the setting of an ARDS-pandemic and the emergence of alternative selective pulmonary vasodilators.

Background: Chronic post-sternotomy pain after coronary artery bypass grafting (CABG) is an underestimated complication. Pain has a major impact on quality of life. Increasingly, low-dose or even opioid-free anesthesia has been shown to be feasible and in some cases beneficial. Different intraoperative analgesic treatment strategies may significantly impact occurrence of hyperalgesia and subsequent pain in cardiac surgery. Objective: To investigate whether different intraoperative dosing regimens of fentanyl during CABG influence the area of hyperalgesia 24 and 48 hours postoperatively. As secondary endpoints, we investigated whether acute postoperative pain measured by the numerical rating scale (NRS) scores at 24 and 48 hours and the occurrence of chronic pain after 3, 6 and 12 months were influenced by perioperative fentanyl dosing. Design: Prospective, randomized double-blind clinical trial. Setting: A preliminary analysis of a randomized multicenter study (University Hospital of Ghent and the University Hospital of Basel), including patients undergoing elective on-pump CABG in University Hospital of Ghent. Methods: We screened 80 patients, of whom 66 were included and randomized into three groups: a high fentanyl regimen (20 µg.kg-1 IBW (Ideal Body Weight)), a low dosing regimen (3 µg.kg-1 IBW), or a Shibutani continuous dosing regimen. When extubated and responsive, protocolized pin-pricking was performed at 24 and 48h to evaluate the surface area of hyperalgesia. Additionally, patients are asked to report the Numeric Rating Scale (NRS) at 24h, 48h, as well as the occurrence of persistent pain at 3, 6, and 12 months. Additional preoperative rescue fentanyl dosing and postoperative remifentanil dosing were taken into account as possible confounders. Results: Primary endpoint: the difference in the measured area of hyperalgesia between the randomization groups was not significantly different. At 24h a mean area of 88 cm2, 90 cm2 and 96 cm2 was found in the low, high and Shibutani groups, respectively. At 48h areas of 91 cm2, 96 cm2 and 103 cm2 were measured in the respective groups. Secondary endpoints: significantly higher NRS scores were recorded at 24 hours in the low-dose group. A higher NRS score was found at 6 months in the Shibutani group compared to the other groups in the longer term. Postoperative administration of remifentanil is was not found to be a confounding cause of hyperalgesia. Conclusion: More short-term pain was reported in patients administered lower doses of fentanyl intraoperatively. Other clinically relevant differences in outcomes were not found. Our findings suggest that the benefits of opioid low anesthesia may not be as relevant to cardiac surgery with median sternotomy. The total postoperative opioid dosing (including remifentanil) could be a possible cause of hyperalgesia. Trial registration: EudraCT (European Union Drug Regulating Authorities Clinical Trials Database), the European database for all interventional clinical trials on medicinal products authorized in the European Union. Eudra CT number: 2017-003278-15, AGO/2017/005.

Background: Thrombocytopenia has been shown to occur soon after surgical biological aortic valve replacement (AVR), and recently reported also after transcatheter valve implantation (TAVI). The mechanism underlying this phenomenon is still unknown, and its clinical impact on the peri-operative outcome has been poorly investigated.Methods: A systematic review and a meta-analysis of all available studies reporting data about periprocedural thrombocytopenia on isolated bio-AVR, comparing rapid-deployment (RDV), stentless (stentless-AVR), and TAVI vs. stented (stented-AVR) valves, have been performed.Results: Fifteen trials (2.163 patients) were included in the meta-analysis. Perioperative platelet reduction ranged from 35% to 55% in stented-AVR, from 60% to 77% in stentless-AVR, from 53% to 60% in RDV, and from to 21% to 72% in TAVI (apparently, balloon-expandable valves more frequently associated to thrombocytopenia). Stented-AVR required more red blood cells transfusion than stentless-AVR (P Conclusions: Thrombocytopenia-related major adverse events were mainly reported in TAVI patients, whereas clinically meaningless in surgical patients. Transient peri-procedural thrombocytopenia is common after bio-AVR, regardless of prosthesis's type or implant modality. It should receive appropriate monitoring and focused investigations. (C) 2019 The Authors. Published by Elsevier B.V.

Postoperative atrial fibrillation (POAF) complicates 20-40% of cardiac surgical procedures and 10-20% of non-cardiac thoracic operations. Typical features include onset at 2-4 days postoperatively, episodes that are often fleeting and a self-limited time course. Associated adverse consequences of POAF include haemodynamic instability, increased risk of stroke, lengthened hospital and intensive care unit stays and greater costs. Underlying mechanisms are incompletely defined but include intraoperative and postoperative phenomena, such as inflammation, sympathetic activation and cardiac ischaemia, that combine to trigger atrial fibrillation, often in the presence of pre-existing factors, making the atria vulnerable to atrial fibrillation induction and maintenance. A better understanding of the underlying mechanisms might enable the identification of new therapeutic targets. POAF can be prevented by targeting autonomic alterations and inflammation. beta-Blocker prophylaxis is the best-established preventive therapy and should be started or continued before cardiac surgery, unless contraindicated. When POAF occurs, rate control usually suffices, and routine rhythm control is unnecessary; rhythm control should be reserved for patients who develop haemodynamic instability or show other indications that rate control alone will be insufficient. In this Review, we summarize the epidemiological and clinical features of POAF, the available pathophysiological evidence from clinical and experimental investigations, the results of prophylactic and therapeutic approaches and the consensus recommendations of various national and international societies.

Postoperative atrial fibrillation (POAF) complicates 20-40% of cardiac surgical procedures and 10-20% of non-cardiac thoracic operations. Typical features include onset at 2-4 days postoperatively, episodes that are often fleeting and a self-limited time course. Associated adverse consequences of POAF include haemodynamic instability, increased risk of stroke, lengthened hospital and intensive care unit stays and greater costs. Underlying mechanisms are incompletely defined but include intraoperative and postoperative phenomena, such as inflammation, sympathetic activation and cardiac ischaemia, that combine to trigger atrial fibrillation, often in the presence of pre-existing factors, making the atria vulnerable to atrial fibrillation induction and maintenance. A better understanding of the underlying mechanisms might enable the identification of new therapeutic targets. POAF can be prevented by targeting autonomic alterations and inflammation. beta-Blocker prophylaxis is the best-established preventive therapy and should be started or continued before cardiac surgery, unless contraindicated. When POAF occurs, rate control usually suffices, and routine rhythm control is unnecessary; rhythm control should be reserved for patients who develop haemodynamic instability or show other indications that rate control alone will be insufficient. In this Review, we summarize the epidemiological and clinical features of POAF, the available pathophysiological evidence from clinical and experimental investigations, the results of prophylactic and therapeutic approaches and the consensus recommendations of various national and international societies.

Background. Complications related to extracorporeal circulation remain serious. Although a minimal invasive extra corporeal circulation (MiECC) system was developed to cope with these complications, its effectivity on patient-related outcomes such as blood loss remain uncertain. Therefore, the aim of this study is to compare MiECC to an advanced standard system with respect to blood loss.Methods. A total of 128 adult patients undergoing elective isolated aortic valve replacement were enrolled in a randomized clinical trial. Patients who had undergone previous heart surgery and with preexisting kidney failure were excluded. The primary end point was postoperative blood loss after 12 hours and at drain removal. Secondary end points included intensive care and total length of stay and intubation time. At 1 hour and 12 hours after surgery, clinical laboratory data were determined. Early clinical outcomes and long-term survival were determined.Results. MiECC patients (n = 63) had a significant lower blood loss (230 mL, 95% confidence interval: 203 to 261 mL) than regular patients (n = 62) after 12 hours (288 mL, 95% confidence interval: 241 to 344 mL, p = 0.04). A preservation of hemoglobin levels 1 hour and 12 hours after surgery in the MiECC group were observed (p Conclusions. This randomized controlled trial compares MiECC and an advanced system for aortic valve replacement with blood loss as primary end point. We conclude that using MiECC is clinically equal for short- and long-term follow-up regarding blood loss. (C) 2019 by The Society of Thoracic Surgeons

Purpose: Whether positive fluid balance among patients with acute kidney injury (AKI) stems from decreased urine output, overzealous fluid administration, or both is poorly characterized. Materials and methods: This was a post hoc analysis of the prospective multicenter observational Finnish Acute Kidney Injury study including 824 AKI and 1162 non-AKI critically ill patients. Results: We matched 616 AKI (diagnosed during the three first intensive care unit (ICU) days) and non-AKI patients using propensity score. During the three first ICU days, AKI patients received median [IQR] of 11.4 L [8.0 & ndash;15.2]L fluids and non-AKI patients 10.2 L [7.5 & ndash;13.7]L, p < 0.001 while the fluid output among AKI patients was 4.7 L [3.0 & ndash;7.2]L and among non-AKI patients 5.8 L [4.1 & ndash;8.0]L, p < 0.001. In AKI patients, the median [IQR] cumulative fluid balance was 2.5 L [& minus;0.2 & ndash;6.0]L compared to 0.9 L [& minus;1.4 & ndash;3.6]L among non-AKI patients, p < 0.001. Among the 824 AKI patients, smaller volumes of fluid input with a multivariable OR of 0.90 (0.88 & ndash;0.93) and better fluid output (multivariable OR 1.12 (1.07 & ndash;1.18)) associated with enhanced change of resolution of AKI. Conclusions: AKI patients received more fluids albeit having lower fluid output compared to matched critically ill non-AKI patients. Smaller volumes of fluid input and higher fluid output were associated with better AKI recovery. (c) 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).

Objective: The aim of this multicenter study was to evaluated whether cold or warm cardioplegia are associated with postoperative atrial fibrillation (POAF) and the prognostic role of the latter on early stroke and neurological mortality.Method: This was a retrospective analysis of prospective collected data from 9 cardiac centers in Italy and the United States including patients undergoing surgery between 2010 and 2018. From the 9 institutional databases, 17,231 patients underwent isolated CABG on-pump, using either warm cardioplegia (n = 7730) or cold cardioplegia (n = 9501); among the latter group blood and crystalloid cardioplegia were used in 691 and 8810 patients, respectively. After matching, two pairs of 4162 patients (overall cohort 8324) were analyzed.Results: In matched population, the rate of POAF was 18% (1472 cases), 15% (608) in warm group versus 21% (864) in cold group (p < 0.001). Multivariable analysis confirmed that cold cardioplegia was associated with higher rate of POAF, along with age, hypercholesterolemia, LVEF, reoperation, preoperative IABP, previous stroke, cardiopulmonary and cross-clamp. Moreover, cold cardioplegia as well as POAF increased the rate of postoperative stroke as well as early mortality and neurological mortality Propensity-weighted cohort included 11,830 (70%) patients out of 17,231. After adjustment, both cold blood and cold crystalloid cardioplegia negatively influenced POAF, stroke and neurological mortality.Conclusions: Warm cardioplegia may reduce the rate of POAF in CABG patients with respect to cold cardioplegia, either blood or crystalloid. This has a prognostic impact on postoperative stroke and neurological mortality. (C) 2020 Elsevier B.V. All rights reserved.

Introduction: Post-operative chronic pain (POCP), after updated by Werner-Kongsgaard, is defined as the pain developed after the surgical procedure or increased in intensity after the procedure, as the continuation of acute postoperative pain, localized in the surgical area, lasted at least 3 months, and other causes of pain excluded. In our study, we aimed to prospectively examine the prevalence of POCP and risk factors in the first three months after coronary artery bypass graft surgery (CABGS). Methods: Between June 2019 and December 2020, a numerical rating scale (NRS) was announced by the study team to evaluate the preoperative pain levels of patients undergoing CABGS in a university hospital. When patients came for the control on the 15th postoperative day, physical examinations were performed, pain status was evaluated, and followed up by phone for three months (30, 60 and 90 days postoperatively). The study, which started with 158 patients, was completed with 110 patients. Results: The patients were divided into two groups as the patients with pain (those with POCP) and the painless group (those without POCP). While there were 39 patients (35.5%) in the group of patients with pain, 71 patients (64.5%) were in the painless group. The proportion of female patients in the group of patients with pain was significantly higher than the painless group (p < 0.05). Conclusions: As a result of our study, postoperative chronic pain is seen in one of every three patients after cardiac surgery. We observed that the risk increased in female patients and in patients with severe preoperative anxiety.

Introduction: This study investigated the role of the neutrophillymphocyte ratio (NLR), the perioperative changes in NLR (deltaNLR), the platelet-lymphocyte ratio (PLR), and the platelet count in predicting acute kidney injury (AKI) following coronary artery bypass grafting (CABG) during hospital stay. Methods: The records of 396 patients with preoperative creatinine < 1.5 mg/dl undergoing isolated CABG between October 2015 and October 2019 were reviewed retrospectively. Diagnosis of AKI was based on the Kidney Disease Improving Global Outcomes definition. Demographic data, operative data, inhospital mortality, preoperative NLR, PLR, and platelet counts were compared between patients with (AKI group) and without (nonAKI group) postoperative AKI. Additionally, NLR, delta-NLR, and PLR values were calculated daily for the first four postoperative days. A subsequent AKI group was formed for the first four postoperative days by excluding patients diagnosed with AKI. The daily and overall predictivity of the markers for AKI are investigated. Results: AKI was present in 86 patients during the postoperative period, while 310 patients had normal postoperative renal functions. NLR, delta-NLR, and PLR on the first four postoperative days (P0.05). Conclusion: NLR values measured on the first four days postoperatively are a useful tool in predicting AKI during hospital stay following CABG. WOS:000674648100011 2-s2.0-85112676294 PubMed: 34387973

Background: The lower limit of cerebral autoregulation (LLA) refers to the mean blood pressure (BP) below which cerebral blood flow becomes pressure-dependent, resulting, among others, in an increased stroke risk. The LLA measured during cardiac surgery, correlates with the vascular measure Ambulatory Arterial Stiffness Index (AASI) determined from intraoperative continuous radial BP before cardiopulmonary bypass [1]. Using these data we investigated added factors that may enhance this correlation. Design and method: The study population included 167 patients undergoing cardiac surgery (age 71 ± 8 years, 68% males) with good-quality BP records. The AASI. Additionally tested predictors were body-mass index (BMI), the coefficient of variation (SD/mean) of the systolic BP (SBP_CV), the composite variables BMI*(1-AASI), and its linear combination with SBP_CV. The odds ratio (OR) was determined by applying logistic regression to dichotomized predictors (by medians) and LLA- (by selected thresholds) adjusted to age, sex, diabetes mellitus, heart rate and preoperative diastolic BP. Results: The Table shows that the LLA of individuals correlated significantly with each of the (continuous) predictors, and the adjusted OR increased for the composite predictors (dichotomized), while showing insensitivity to adjustors. The ORs reached a maximum for a LLA threshold of 55 mmHg. Predictor Univariate regression Adjusted OR r (p-value) Mean [95% CI] (p-value) AASI 0.27 (0.0004) 2.41 [1.16–5.00] (0.02) BMI −0.26 (0.0007) 3.77 [1.78–8.00] (0.0005) SBP_CV −0.29 (0.0002) 3.50 [1.71–7.16] (0.0006) BMI*(1-AASI) −0.35 (0.000005) 4.51 [2.16–9.40] (0.00006) 80*SBP_CV + BMI*(1-AASI) −0.44 (

Adults with congenital heart disease (ACHD) represent a growing population. To evaluate frequency, type and outcomes of cardiac surgery in ACHD, we gathered data from the European Congenital Heart Surgeons Association Database of 20,602 adult patients (≥18 years) with a diagnosis of congenital heart disease who underwent cardiac surgery, between January 1997 and December 2017. We demonstrated that overall surgical workload (as absolute frequencies of surgical procedures per year) for this specific subset of patients increased steadily during the study period. The most common procedural groups included septal defects repair (n = 5740, 28%), right-heart lesions repair (n = 5542, 27%) and left-heart lesions repair (n = 4566, 22%), almost one-third of the procedures were re-operations (n = 5509, 27%). When considering the year-by-year relative frequencies of the main procedural groups, we observed a variation of the surgical scenario during the last two decades, characterized by a significant increase over time for right and left-heart lesions repair (p &lt, 0.0001, both), while a significant decrease was seen for septal defects repair (p &lt, 0.0001) and transplant (p = 0.03). Overall hospital mortality was 3% (n = 622/20,602 patients) and was stable over time. An inverse relationship between mortality and the number of patients operated in each center (p &lt, 0.0001) was observed.

Objective: The aim of the present study was to identify whether the decrease of longitudinal parameters after cardiothoracic surgery (ie, tricuspid annular systolic plane excursion [TAPSE] and systolic excursion velocity [S']) is accompanied by a reduction in global right ventricular (RV) performance. Design: Prospective, observational study. Setting: Single-center explorative study in a tertiary teaching hospital. Participants: The study comprised 20 patients who underwent aortic valve replacement with or without coronary artery bypass grafting. Interventions: During cardiac surgery, simultaneous measurements of RV function were performed with a pulmonary artery catheter and transesophageal echocardiography. Measurements and Main Results: TAPSE and S’ were reduced significantly directly after surgery compared with the time before surgery (TAPSE from 20.8 [16.6-23.4] mm to 9.1 [5.6-15.5] mm; p < 0.001 and S’ from 8.7 [7.9-10.7] cm/s to 7.2 [5.7-8.6] cm/s; p = 0.041). However, the reduction in TAPSE and S’ was not accompanied by a reduction in RV performance, as assessed with the TEE-derived myocardial performance index (MPI) and pulmonary artery catheter–derived RV ejection fraction (RVEF). Both remained statistically unaltered before and after the procedure (MPI from 0.52 [0.43-0.58] to 0.50 [0.42-0.88]; p = 0.278 and RVEF from 27% [22%-32%] to 26% [22%-28%]; p = 0.294). Conclusions: In the direct postoperative phase, the reduction of echocardiographic parameters of longitudinal RV contractility (TAPSE and S’) were not accompanied by a reduction in global RV performance, expressed as MPI and RVEF. Solely relying on a single RV parameter as a marker for global RV performance may not be adequate to assess the complex adaptation of the right ventricle to aortic valve replacement.

BACKGROUND: Recent studies in haemodynamic management have focused on fluid management and assessed its effects in terms of increase in cardiac output based on fluid challenges or variations in pulse pressure caused by cyclical positive pressure ventilation. The theoretical scope may be characterised as Starling-oriented. This approach ignores the actual events of right-sided excitation and left-sided response which is consistently described in a Guyton-oriented model of the cardiovascular system.AIM: Based on data from a previous study, we aim to elucidate the primary response to crystalloid and colloid fluids in terms of cardiac output, mean blood pressure and right atrial pressure as well as derived and efficiency variables defined in terms of Guyton venous return physiology.METHOD: Re-analyses of previously published data.RESULTS: Cardiac output invariably increased on infusion of crystalloid and colloid solutions, whereas static and dynamic efficiency measures declined in spite of increasing pressure gradient for venous return.DISCUSSION: We argue that primary as well as derived and efficiency measures should be reported and discussed when haemodynamic studies are reported involving fluid administrations.

Congenital heart disease (CHD) is the most common anatomical malformation occurring live-born infants and an increasing cause of morbidity and mortality across the lifespan and throughout the world. Population-based observations have long described associations between maternal cardiometabolic disorders and the risk of CHD in the offspring. Here we review the epidemiological evidence and clinical observations relating maternal obesity and diabetes mellitus to the risk of CHD offspring with particular attention to mechanistic models of maternal-fetal risk transmission and first trimester disturbances of fetal cardiac development. A deeper understanding of maternal risk factors holds the potential to improve both prenatal detection of CHD by identifying at-risk pregnancies, along with primary prevention of disease by improving preconception and prenatal treatment of at-risk mothers.

Reoperative mitral valve surgery (MVS) through a median sternotomy (ST-MVS) can be particularly challenging due to dense adhesions and is known to carry a substantial risk of injuries to vascular structures. These injuries occur in 7-9% of cases and are associated with increased mortality rates. A valid alternative that could avoid the risks associated with redo ST-MVS is the right anterolateral minithoracotomy (MT-MVS) approach. The aim of this study was to quantify the effects of MT-MVS compared with those of ST-MVS on morbidity and mortality among patients who underwent prior cardiac surgery through a sternotomy. The MEDLINE and EMBASE databases were searched through 1 November 2017. Data regarding mortality, stroke, reoperation for bleeding and length of hospital stay were extracted and submitted to a meta-analysis using random effects modelling and the I-2-test for heterogeneity. Six retrospective observational studies were included, enrolling a total of 777 patients. In a pooled analysis, MT-MVS demonstrated reduced mortality rates compared to a standard sternotomy [odds ratio (OR) 0.41, 95% confidence interval (CI) 0.18-0.96; P = 0.04]. MT-MVS was, moreover, associated with reduced length of hospital stay [difference between the means was -3.81, 95% CI -5.53 to -2.08; P

PURPOSE OF REVIEW: The current review attempts to demonstrate the value of several forms of carbon dioxide (CO2) gaps in resuscitation of the critically ill patient as monitor for the adequacy of the circulation, as target for fluid resuscitation and also as predictor for outcome.RECENT FINDINGS: Fluid resuscitation is one of the key treatments in many intensive care patients. It remains a challenge in daily practice as both a shortage and an overload in intravascular volume are potentially harmful. Many different approaches have been developed for use as target of fluid resuscitation. CO2 gaps can be used as surrogate for the adequacy of cardiac output (CO) and as marker for tissue perfusion and are therefore a potential target for resuscitation. CO2 gaps are easily measured via point-of-care analysers. We shed light on its potential use as nowadays it is not widely used in clinical practice despite its potential. Many studies were conducted on partial CO2 pressure differences or CO2 content (cCO2) differences either alone, or in combination with other markers for outcome or resuscitation adequacy. Furthermore, some studies deal with CO2 gap to O2 gap ratios as target for goal-directed fluid therapy or as marker for outcome.SUMMARY: CO2 gap is a sensitive marker of tissue hypoperfusion, with added value over traditional markers of tissue hypoxia in situations in which an oxygen diffusion barrier exists such as in tissue oedema and impaired microcirculation. Venous-to-arterial cCO2 or partial pressure gaps can be used to evaluate whether attempts to increase CO should be made. Considering the potential of the several forms of CO2 measurements and its ease of use via point-of-care analysers, it is recommendable to implement CO2 gaps in standard clinical practice.

Purpose of review The current review attempts to demonstrate the value of several forms of carbon dioxide (CO2) gaps in resuscitation of the critically ill patient as monitor for the adequacy of the circulation, as target for fluid resuscitation and also as predictor for outcome. Recent findings Fluid resuscitation is one of the key treatments in many intensive care patients. It remains a challenge in daily practice as both a shortage and an overload in intravascular volume are potentially harmful. Many different approaches have been developed for use as target of fluid resuscitation. CO2 gaps can be used as surrogate for the adequacy of cardiac output (CO) and as marker for tissue perfusion and are therefore a potential target for resuscitation. CO2 gaps are easily measured via point-of-care analysers. We shed light on its potential use as nowadays it is not widely used in clinical practice despite its potential. Many studies were conducted on partial CO2 pressure differences or CO2 content (cCO2) differences either alone, or in combination with other markers for outcome or resuscitation adequacy. Furthermore, some studies deal with CO2 gap to O2 gap ratios as target for goal-directed fluid therapy or as marker for outcome. Summary CO2 gap is a sensitive marker of tissue hypoperfusion, with added value over traditional markers of tissue hypoxia in situations in which an oxygen diffusion barrier exists such as in tissue oedema and impaired microcirculation. Venous-to-arterial cCO2 or partial pressure gaps can be used to evaluate whether attempts to increase CO should be made. Considering the potential of the several forms of CO2 measurements and its ease of use via point-of-care analysers, it is recommendable to implement CO2 gaps in standard clinical practice.

BACKGROUND: The use of the intra-aortic balloon pump (IABP) as a support device remains controversial due to the fact that a number of studies have shown no benefit in end mortality whilst using this device. One of the reasons for this could be the increase in vascular complications when using the pump. Therefore, the aim of the present review was to assess the current literature available with regards to IABP vascular complications during the clinical situation.METHODS: A literature search was performed, searching for IABP complications in adult human studies between 1990 and 2016.RESULTS: A total of 20 reports were identified as fitting the criteria of this study. The majority of vascular complications were limb ischemia, bleeding or mesenteric ischemia. The overall incidence of vascular complications ranged from 0.94% to 31.1%. Diabetes, peripheral vascular disease and hypertension, as well as smoking were all identified as risk factors for complications following IABP. Furthermore, studies supported the use of sheathless balloon insertion to reduce the risk of complications.CONCLUSION: Major vascular complications, including limb and mesenteric ischemia as well as bleeding and hemorrhage, have been associated with IABP. However, the incidence of these complications was generally low. Further studies are still required to truly understand the risk/benefit associated with the use of IABP.

Background and Aims: Acute kidney injury (AKI) following cardiac surgery is a major complication resulting in increased morbidity, mortality and economic burden. This study was designed to determine the benefit of sodium bicarbonate (NaHCO3) supplementation in patients with stable chronic kidney disease (CKD) undergoing off-pump coronary artery bypass grafting (OP-CABG). Material and Methods: We prospectively studied 60 non-dialysis CKD patients with glomerular filtration rate (GFR)

This review provides an overview of the clinical value of themost relevant renal biomarkers, focusing on two main clinical conditions: acute kidney injury and chronic kidney disease. We categorize biomarkers according to their actionability, in terms of a documented response to treatment in relation to outcomes. Furthermore, we introduce a new category of renal biomarkers, metabolic biomarkers, and underscore their capacity to be highly actionable.

ObjectivesTreating the precipitating factors of delirium is the mainstay of the prevention and treatment of delirium. We aim to investigate the role of anemia and blood transfusion within the multicomponent prevention and treatment strategy of delirium.DesignSystematic review.SettingWe included cohort studies or Randomized Controlled Trials (RCTs) that considered blood transfusion as treatment for delirium or risk factor, and had delirium as outcome.ParticipantsHospitalized patients above 55 years old.MeasurementsWe searched MEDLINE from 1946 through November 2014. Quality assessment and data extraction were performed systematically.ResultsWe included 23 studies (n = 29,471). The majority of the studies (n = 22) had a limited quality and for one study quality was uncertain. Two studies evaluated the association between transfusion strategy and postoperative delirium and found no association. Twenty-one studies investigated blood transfusion as a risk factor for delirium. In four of the 21 studies it could be assumed that delirium occurred after transfusion. One of these studies stated that transfusion was a significant risk factor for subsequent delirium (odds ratio (OR) = 3.68, 95% confidence interval (CI) = 1.32-10.94). The other three studies found no association between transfusion and delirium. In the remaining 17 studies, it was not clear whether delirium occurred before or after transfusion, so no conclusion could be drawn on the role of transfusion in delirium development.ConclusionThe majority of the included studies was not suited to answer the research question properly as the time course of the beginning of delirium as to transfusion was lacking. Our review shows that there is no good quality evidence available for blood transfusion to be a risk factor for delirium or to be a preventive or treatment option.

Background:Children with complex CHD are at risk for psychopathology such as severe attention-deficit/hyperactivity disorder symptoms after congenital heart surgery.Objective:The aim of this study was to investigate if children with Ventricular Septal Defect, Transposition of Great Arteries, or Tetralogy of Fallot have an increased occurrence of attention-deficit/hyperactivity disorder symptoms compared with the background population and to investigate differences between the three CHDs in terms of occurrence and appearance of attention-deficit/hyperactivity disorder symptoms.Method:A national register-based survey was conducted, including children aged 10–16 years with surgically corrected CHDs without genetic abnormalities and syndromes. The Attention-Deficit/Hyperactivity Disorder-Rating Scale questionnaires were filled in by parents and school teachers.Results:In total, 159 out of 283 questionnaires were completed among children with CHDs and compared with age- and sex-matched controls. Children with CHDs had significantly increased inattention scores (p = 0.009) and total attention-deficit/hyperactivity disorder scores (p = 0.008) compared with controls. Post hoc analyses revealed that children with Tetralogy of Fallot had significantly higher inattention scores compared with children both with Ventricular Septal Defect (p = 0.043) and controls (p = 0.004).Conclusion:Attention-deficit/hyperactivity disorder symptoms and inattention symptoms were significantly more frequent among children aged 10–16 years with CHDs, in particular in children with corrected Tetralogy of Fallot.

The number of high-risk patients undergoing surgery is growing. To maintain adequate hemodynamic functioning as well as oxygen delivery to the vital organs (DO2) amongst this patient population, a rapid assessment of cardiac functioning is essential for the anesthesiologist. Pinpointing any underlying cardiovascular pathophysiology can be decisive to guide interventions in the intraoperative setting. Various techniques are available to monitor the hemodynamic status of the patient, however due to intrinsic limitations, many of these methods may not be able to directly identify the underlying cause of cardiovascular impairment. Hemodynamic focused echocardiography, as a rapid diagnostic method, offers an excellent opportunity to examine signs of filling impairment, cardiac preload, myocardial contractility and the function of the heart valves. We thus propose a 6-step-echocardiographic approach to assess high-risk patients in order to improve and maintain perioperative DO2. The summary of all echocardiographic based findings allows a differentiated assessment of the patient's cardiovascular function and can thus help guide a (patho)physiological-orientated and individualized hemodynamic therapy.

Postoperative atrial fibrillation (POAF) in relation to abdominal surgery can cause clinical deterioration, prolonged hospitalization, admittance to intensive care units, stroke and increased mortality. The current review focus on patients developing POAF in relation to abdominal surgery and aims to present the current knowledge on predictors of this condition. Furthermore, predictors identified in other surgical populations that may be transferable and guide future research within the field of abdominal surgery will be presented. A systematic literature search of patients undergoing abdominal surgery and developing POAF was performed on PubMed and Embase. All types of study interventions, comparators and designs were included. All studies included reported POAF as primary or secondary outcome. All peer-reviewed English full-text manuscripts regardless of publication date were included. We included five studies out of the 149 unique records identified. Age, congestive heart failure, hypertension, vascular disease and surgical approach are risk factors associated with the development of POAF. Furthermore, inflammation biomarkers, dobutamine stress echocardiography and cardiac single-photon emission computed tomography can predict POAF. Insights from other surgical cohorts reveal that other biomarkers (ie, brain natriuretic peptide (BNP) and N-terminal pro-BNP), electrocardiography and echocardiography can be used to predict POAF and may be applied in future research projects within the field of abdominal surgery. In conclusion, very scarce evidence is currently available in predicting POAF after abdominal surgery. However, predicting POAF seems possible and feasible, why the authors encourage readers to initiate new research to close the current knowledge gap and improve clinical management.