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Delirium after cardiac surgery is associated with prolonged intensive care unit (ICU) and hospital length of stay and elevated rates of mortality. The Society of Thoracic Surgery National Database (STS-ND) includes delirium in routine data collection but restricts its definition to hyperactive symptoms. The objective is to determine whether the Confusion Assessment Method for ICU (CAM-ICU), which includes hypo- and hyperactive symptoms, is associated with improved prediction of poor 1-year functional survival following cardiac surgery.Clinical and administrative databases were used to determine the influence of postoperative delirium on 1-year poor functional survival, defined as being institutionalized or deceased at 1 year. Patients experiencing postoperative delirium using the STS-ND definition (2007-2009) were compared with patients with delirium identified by the CAM-ICU (2010-2012). A propensity score match was undertaken, and multivariable Cox proportional hazards regression models were generated to determine risk of poor 1-year functional survival.There were 2756 and 2236 patients in the STS-ND and CAM-ICU cohorts, respectively. Propensity matching resulted in a cohort of 1835 patients (82.1% matched). The overall rate of delirium in the matched study population was 7.6% in the STS-ND cohort and 13.0% in the CAM-ICU cohort (P .001). Delirium in the CAM-ICU cohort was independently associated with poor 1-year functional survival (hazard ratio, 2.58; 95% confidence interval, 1.20-5.54; P = .02); delirium in the STS-ND cohort was not associated with poor 1-year functional survival (hazard ratio, 0.92; 95% confidence interval, 0.49-1.71; P = .79).A systematic screening tool identifies postoperative delirium with improved prediction of poor 1-year functional survival following cardiac surgery.

Background: Current intensive care unit physician-staffing (IPS) models for postoperative cardiac surgery have not been previously investigated in Canada. The purpose of this study was to determine current IPS models at 2 time points and describe the evolution of Canadian cardiac surgery IPS models. Methods: A survey of 32 Canadian cardiovascular intensive care units (CVICUs) was undertaken in 2012 and 2017 to determine IPS models of care during “daytime” and “after-hours” in each unit. Data were collected regarding surgical volume, base specialties, and style of IPS management (“open”; “semi-open”; “closed”). In addition, we collected the overnight experience level of the bedside healthcare provider for in-house intensive care units. Results: Survey responses were received from 27 of 32 CVICUs (87%). As of 2017, the style of 1 (4%) was open, 7 (26%) were semi-open, and 19 (70%) were closed in their unit IPS strategy. Base specialties of CVICU physicians varied. A medical doctor provided after-hours coverage in 81% of CVICUs. Senior residents (37%) or critical care certified attending staff (25%) typically provided after-hours coverage for in-house CVICUs. Linked Canadian Institute for Health Information data did not indicate a difference among CVICU models in mortality or rehospitalization for coronary artery bypass graft or valve procedures. Conclusions: Considerable heterogeneity is demonstrated in CVICU staffing patterns. No consensus was identified regarding the appropriate level of training for “after-hours” coverage. In-house overnight physician staffing in CVICUs varies widely. Finally, semi-open and closed style models did not demonstrate differences compared to Canadian Institute for Health Information data. Variability among CVICUs does exist; however, benefits of one model over another have not been identified. Résumé: Introduction: Les modèles actuels de dotation en médecins aux soins intensifs (DMSI) postopératoires de chirurgie cardiaque n’ont pas fait l’objet d’études antérieures au Canada. L’objectif de la présente étude était de déterminer les modèles actuels de DMSI à deux points temporels et de décrire l’évolution des modèles de DMSI de chirurgie cardiaque au Canada. Méthodes: Nous avons entrepris une enquête auprès de 32 unités de soins intensifs cardiovasculaires du Canada (USICC) en 2012 et en 2017 pour déterminer les modèles de soins DMSI « pendant la journée » et « après les heures normales » dans chaque unité. Nous avons collecté les données relatives au volume d’interventions chi- rurgicales, aux spécialités de base et au style de gestion de la DMSI (« ouvert », « semi-ouvert », « fermé »). De plus, nous avons collecté les données sur le niveau d’expérience de nuit des prestataires de soins au chevet des patients des unités intégrées de soins intensifs. Résultats: Nous avons reçu les réponses à l’enquête de 27 des 32 USICC (87 %). Depuis 2017, le style de 1 (4 %) USICC était ouvert, de 7 (26 %) était semi-ouvert et de 19 (70 %) était fermé dans leur stra- tégie de DMSI à l’unité. Les spécialités de base des médecins de l’USICC variaient. Un docteur en médecine offrait ses services après les heures normales dans 81 % des USICC. Les résidents chevronnés (37 %) ou les médecins titulaires agréés en soins aux patients en phase critique (25 %) offraient habituellement leurs services après les heures normales aux USICC intégrées. Les données liées de l’Institut canadien d’information sur la santé n’indiquaient pas de différence entre les modèles des USICC en ce qui a trait à la mortalité ou à la réhospitalisation en raison de pontages aortocoronariens ou d’interventions valvulaires. Conclusions: Les modèles de dotation en personnel aux USICC démontrent une importante hétérogénéité. Aucun consensus n’a été établi quant au niveau approprié de formation pour les services offerts « après les heures normales ». Le personnel médical de nuit à l’interne des USICC varie grandement. Finalement, les modèles de styles semi-ouverts et fermés ne démontraient pas de différence par rapport aux données de l’Institut canadien d’information sur la santé. Une variabilité existe entre les USICC. Toutefois, les avantages d’un modèle par rapport à un autre n’ont pas été définis.

Cardiac output (CO) and other hemodynamic parameter measurements play an important role in the management of cardiovascular conditions; however, due to limitations of current day technologies, such measurements are either not routinely performed or incorporated into clinical practice. Moreover, measurement of these hemodynamic parameters in the outpatient setting at different time points to assess interval change is currently not feasible. We attempted to validate total-body impedance cardiography-based Non-Invasive Cardiac System (NICaS) derived stroke volume (SV) with that from cardiac magnetic resonance (CMR), a current day gold standard method of assessment. We compared SV, as it is the primary unit of measurement utilized by both technologies. Forty-one consecutive patients undergoing CMR were also investigated by NICaS following CMR. The consistency of non-invasive technology-derived SV measurement was validated by NICaS measurement in 10 subjects, both before and after CMR. Of the 41 enrolled patients; data from 38 patients was adequate for comparison (motion artifact prevented CMR measures in 3 patients). Fourteen patients (37%) were female; mean age was 55 ± 15 years (28-87 years) and body-mass index was 28.7 ± 5.5 kg/m

Background: Recently, anecdotal evidence suggested an increase in infective endocarditis (IE) in Manitoba driven by an increasing proportion of patients with intravenous drug use (IVDU)-associated endocarditis. This study aimed to characterize the observed changing incidence and epidemiology of IE. Methods: This retrospective study evaluated consecutive patients >18 years old with an International Classification of Disease–10 diagnosis of IE who presented to a tertiary referral center in Winnipeg, Manitoba between January 1, 2004 and December 31, 2018. Data were obtained by individual review of paper and electronic medical records and entered into the Research Electronic Data Capture database. Mortality and hospital readmission data were acquired by linking Research Electronic Data Capture data to the Manitoba Centre for Health Policy, which prospectively maintains a comprehensive population-based health database. Results: A total of 612 cases of IE were identified. The incidence of IE increased from 2.03 per 100,000 in 2004 to 5.16 per 100,000 in 2018, with IVDU-associated cases increasing from 0.11 to 2.87 per 100,000. Left heart vegetations were most common in the non-IVDU group, whereas right-sided vegetations dominated in the IVDU group. All-cause mortality did not differ between IVDU and non-IVDU IE, despite a significantly younger age in patients with IVDU. The IVDU group showed a higher rate of endocarditis recurrence. Conclusions: In this first study to examine the longitudinal incidence of IE in Manitoba, we showed that the incidence of IE has significantly increased over the last 15 years, with a contribution of IVDU-associated IE that has a high rate of mortality and disease recurrence. Résumé: Introduction: Des données anecdotiques récentes montraient une augmentation de l’endocardite infectieuse (EI) au Manitoba attribuable à la proportion accrue de patients atteints d’une endocardite associée à l’usage de drogues par voie intraveineuse (UDVI). La présente étude avait pour but de caractériser les changements observés dans l’incidence et l’épidémiologie de l’EI. Méthodes: Cette étude rétrospective a permis d’évaluer les patients consécutifs > 18 ans qui avaient un diagnostic d’EI conformément à la Classification internationale des maladies, 10e révision, et qui s’étaient présentés dans un centre d’aiguillage en soins tertiaires de Winnipeg, au Manitoba, entre le 1er janvier 2004 et le 31 décembre 2018. Nous avons obtenu les données par l’examen du dossier individuel et des dossiers médicaux électroniques de la base de données Research Electronic Data Capture. Nous avons obtenu les données sur la mortalité et les réadmissions à l’hôpital par la liaison des données de la Research Electronic Data Capture au Manitoba Centre for Health Policy, qui maintient de manière prospective une base de données exhaustive sur la santé de la population. Résultats: Nous avons trouvé un total de 612 cas d’EI. L’incidence de l’EI est passée de 2,03 par 100 000 en 2004 à 5,16 par 100 000 en 2018, et l’incidence des cas d’EI associée à l’UDVI, de 0,11 à 2,87 par 100 000. Les végétations du cœur gauche étaient plus fréquentes dans le groupe de patients atteints d’une EI non associée à l’UDVI, alors que les végétations du cœur droit dominaient dans le groupe de patients atteints d’une EI associée à l’UDVI. La mortalité toutes causes confondues ne différait pas entre les patients atteints d’une EI associée à l’UDVI ou non associée à l’UDVI, en dépit de l’âge significativement plus jeune des patients atteints d’une EI associée à l’UDVI. Le groupe de patients atteints d’une EI associée à l’UDVI montrait un taux plus élevé de récurrence de l’endocardite. Conclusions: Dans cette première étude, qui portait sur l’incidence longitudinale de l’EI au Manitoba, nous avons montré que l’incidence de l’EI avait considérablement augmenté au cours des 15 dernières années, puisque l’EI associée à l’UDVI a contribué à l’augmentation du taux de mortalité et de récurrence de la maladie.

At present, there is a lack of information on patient and caregiver values, and perceived priorities and barriers, to guide successful post-discharge recovery. This was a single center, multiple methods study that investigated patient, caregiver, and health care provider perceptions of the discharge process after cardiac surgery. Themes emerging from focus group discussions with patients and caregivers were used to develop surveys relating to values, barriers, and challenges relating to the discharge process. Thirty-two patients (n = 16) and caregivers (n = 16) participated in four separate focus groups. Four themes emerged from these discussions: (1) a lack of understanding about what the discharge process entails and when discharge is appropriate, (2) issues relating to the information provided to patients at the time of discharge, (3) participant experiences with the health care system, and (4) the experiences of caregivers. Seventy-eight patients, 34 caregivers, 53 nurses and/or other allied health professionals, and 8 surgeons completed the cross-sectional surveys. The most important component of the discharge process for patients and caregivers was "knowing what to do in an emergency." Health care providers less accurately identified what caregivers perceived as the most important aspects of the discharge process.Statements relating to informational barriers to discharge were the most discordant among patient and caregiver respondents. After discharge, patients and caregivers identified the need for longer-term follow up with the surgeon and more support in the community. Incorporation of patient and caregiver values to guide the post-cardiac surgery discharge process is essential to promote successful recovery.

Background: Health care resource utilization for patients with adult congenital heart disease (ACHD) has not been well characterized outside of large Canadian specialized regional centres. We sought to describe the ACHD population and resource utilization patterns seen in a medium regional Canadian centre providing specialized ACHD care. Methods: A cross-sectional retrospective study was done from a sample of patients seen in 2018 at the ACHD clinic in Manitoba, Canada. Demographic data were collected along with cardiac anatomy and repair type. Health care resource utilization, clinic visits, hospital admissions, unexpected hospital presentations, and cardiac interventions were measured over a 5-year period. Results: A random sample of 262 patients was selected from our specialized ACHD clinic. Mean age was 33.5 (±13.7) years; 48% of the population was female, and >50% resided within the major city limits. A total of 21% of the population had simple anatomy, 44% had moderate anatomy, and 35% had complex anatomy. The most commonly used imaging modality was echocardiography, followed by cardiac magnetic resonance imaging, with more frequent imaging done in patients with complex anatomy. Unexpected hospital encounters occurred at a rate of 16 per 100 person-years. Total inpatient hospital days occurred at a rate of 33 per 100 person-years, and visits to the congenital clinic occurred at a rate of 90 per 100 person-years. Conclusions: Health care resource utilization appears to be highest in older adults and those with more complex ACHD anatomy. As the overall cohort of adults with ACHD continues to age, resource needs are likely to increase. Résumé: Contexte: L'utilisation des ressources de santé à l'extérieur des grands centres spécialisés régionaux au Canada n'a pas été bien caractérisée pour les patients atteints de cardiopathie congénitale de l'adulte (CCA). Nous avons cherché à décrire la population atteinte de CCA et les schémas d'utilisation des ressources observés dans un centre régional canadien de taille moyenne fournissant des soins spécialisés en CCA. Méthodologie: Une étude transversale rétrospective a été réalisée à partir d'un échantillon de patients rencontrés en 2018 dans une clinique spécialisée en CCA du Manitoba, au Canada. Des données démographiques ont été recueillies de même que des données sur l'anatomie cardiaque et le type de réparation. L'utilisation des ressources de soins de santé, les visites à la clinique, les admissions à l'hôpital, les consultions hospitalières imprévues et les interventions cardiaques ont été mesurées sur une période de cinq ans. Résultats: Un échantillon aléatoire de 262 patients a été sélectionné dans notre clinique spécialisée en CCA. L’âge moyen des patients était de 33,5 (±13,7) ans; 48 % de la population était de sexe féminin et plus de 50 % résidait dans les limites d'une grande ville. Au total, 21 % de la population présentait une anatomie cardiaque simple, 44 % une anatomie modérément complexe et 35 % une anatomie complexe. La technique d'imagerie la plus utilisée était l’échocardiographie, suivie de l'imagerie par résonance magnétique cardiaque, l'imagerie étant plus fréquente chez les patients présentant une anatomie cardiaque complexe. Le taux de consultations hospitalières imprévues était de 16 pour 100 années-patient. Le nombre total de jours d'hospitalisation était de 33 pour 100 années-patient, et le nombre de visites à la clinique spécialisée en CCA était de 90 pour 100 années-patient. Conclusions: L'utilisation des ressources de soins de santé semble être plus élevée chez les adultes plus âgés et chez ceux qui présentent une anatomie plus complexe liée à la CCA. Puisque l'ensemble de la cohorte d'adultes atteints de CCA continue de vieillir, les besoins en ressources sont susceptibles d'augmenter.

Objective To characterize the institutional oxygen management practices during cardiopulmonary bypass (CPB) in patients undergoing cardiac surgery, including any potential changes during an 8-year study period. Design A retrospective cohort study. Setting A tertiary care cardiac surgical program. Participants Patients who underwent cardiac surgery involving CPB, with or without hypothermic circulatory arrest (HCA), between January 1, 2010, and December 31, 2017. Measurements and Main Results In addition to baseline patient characteristics, the authors recorded the partial pressures of arterial oxygen (Pa o 2), fraction of inspired oxygen, and mixed venous oxygen saturation during CPB of 696 randomly selected patients during an 8-year study period. The overall mean Pa o 2 was 255 ± 48 mmHg, without any significant change during the 8-year study period (p = 0.30). The mean Pa o 2 of HCA patients was significantly higher than in patients without HCA (327 ± 93 mmHg v 252 ± 45 mmHg, respectively; p Conclusions The current approach to oxygen management during CPB at the authors’ institution is within the range of hyperoxemic levels, and these practices have not changed over time. The impact of these practices on patients’ outcomes is not fully understood, and additional studies are needed to establish firm evidence to guide optimal oxygen management practice during CPB.

Aims Aldosterone has been found to influence cancer cell growth, cell cycle regulation and cell migration, including in prostate cancer cells. Spironolactone is an aldosterone antagonist used for managing chronic heart failure (HF) with known antiandrogenic effects. We examined the effect of spironolactone exposure amongst men with HF on the incidence of prostate cancer. Methods This retrospective cohort study utilized provincial clinical and administrative databases from the Manitoba Centre for Health Policy. Incident cases of prostate cancer were identified from the provincial cancer registry, and spironolactone exposure was quantified from pharmacare databases. A multivariable proportional hazards model was used to assess the time-dependent impact of spironolactone exposure on prostate cancer incidence. Results A total of 18 562 men with newly diagnosed HF from 2007 to 2015 with a median age of 72 years (interquartile range: 61-81) and a median follow-up from HF diagnosis to prostate cancer incidence of 2.7 years (interquartile range: 1.1-4.9) were included. A time-dependent multivariable analysis of spironolactone exposure following HF diagnosis found a reduced the risk of prostate cancer hazard ratio 0.55 (95% confidence interval 0.31-0.98, P = .043). Conclusion Spironolactone exposure significantly reduced the incidence of prostate cancer amongst men with HF. These findings support the plausibility of aldosterone as a promoter of prostate cancer growth and development. Prospective clinical trials are warranted to further assess the role of spironolactone or other mineralocorticoid receptor antagonists as a means to prevent prostate cancer development or as an adjunctive measure to prostate cancer treatments.

A retrospective study of medically treated isolated left-sided infective endocarditis (LSIE) patients identifying predictors of outcomes with nonoperative management was undertaken.Medical records of 135 Manitoban medically managed LSIE patients from January 2004 to December 2016 were reviewed. Five-year survival for 135 patients and hospitalization data till March 2016 for 65 patients were collected from the Manitoba Centre for Health Policy.In-hospital mortality was 44%. Patients with surgical indications were more likely to die in-hospital than those without (53% vs 24%; P = 0.002). Survival at 1 and 5 years was 43% and 23%, respectively. All-cause readmission at 1 and 5 years was 64% and 84%, respectively. At 1 and 5 years, readmission from major adverse events (heart failure, stroke, endocarditis) was 25% and 47%, and from recurrent endocarditis was 17% and 26%, respectively. Severe valvular regurgitation was a risk factor for in-hospital mortality (odds ratio, 3.52; P = 0.022), poor long-term survival (hazard ratio [HR], 2.57; P0.001), and recurrent endocarditis (HR, 5.93; P 0.001). Prosthetic valve endocarditis was a risk factor for poor long-term survival (HR, 2.11; P = 0.002). Streptococcus viridans group was associated with better rates of in-hospital mortality (odds ratio, 0.28; P = 0.018) and long-term survival (HR, 0.34; P0.001).Nonoperative management of LSIE carries a poor prognosis but may have a role in select cases. Surgical management remains the mainstay for patients with clear surgical indications, including severe regurgitation and prosthetic valve endocarditis. Further prospective analyses are required to better delineate appropriate patient selection for nonsurgical management.

Introduction: In stark contrast to a ~3-5% in-hospital mortality in all comer ST Elevation Myocardial Infarction (STEMI) patients, ~40-50% of STEMI patients complicated by cardiogenic shock (CS) die during their index-hospital admission. None of the pharmaco-mechanical circulatory support therapies have demonstrated survival benefit in CS, likely due to our inability to objectively define and identify CS in the “pre-shock” state. As per the current guidelines, CS is defined as either (1) systolic blood pressure (SBP) ≤ 90mmHg, (2) cardiac-index (CI) 2 or 2 with inotropic/vasopressor support in presence of pulmonary capillary wedge pressure ≥15 mmHg, and/or (3) lactate >2 mmol/L. These parameters are used interchangeably. however, data comparing these parameters is lacking. Objective: (1) To identify the incidence of CS using the above three parameters, and (2) assess the concordance between these parameters in STEMI patients . Methods: CI (total body impedance method), SBP and lactate were measured pre- and post-primary percutaneous coronary intervention (PPCI) in consecutive STEMI patients. Results: Sixty-eight STEMI patients (32% female) with a mean age of 65.8 years were recruited. Based upon lactate, CI and SBP the incidence of CS pre-PPCI was 47%, 26% and 17% (Panel-A). Poor concordance was seen between all three parameters. SBP and CI (R 0.466, R 2 0.220; Panel-B), CI and lactate (R -0.228, R 2 0.052; Panel-C), as well as SBP and lactate (R -0.314, R 2 0.098; Panel-D) criteria predominantly identified different patient cohorts, with minimal overlap; demonstrating that these parameters cannot be used interchangeably. Conclusion: Our study is the first to describe poor congruity between the current parameters defining CS. Such limitations raise the need of objectively defining CS so that these high-risk patients can be identified early in the course of CS (pre-CS state), where timely interventions are likely to improve the outcomes.

Patients following cardiac surgery commonly experience post-operative delirium (POD) during their postoperative hospital stay. A multifaceted, specialty wide, quality improvement (QI) project was undertaken for patients experiencing POD. The goal was to develop a reduction in POD care bundle (rPOD-a structured patient care program) that encompasses efficient preoperative risk factor identification and a postoperative patient-care process to ensure early POD identification and treatment. The following steps were taken to implement the rPOD care bundle including: (a) Developing a quality driven, evidence-based guideline for the perioperative cardiac surgery health care team, (b) identifying and addressing local barriers to implementation, (c) selecting performance measures to assess intervention adherence and patient outcomes, and (d) ensuring that all patients receive the interventions through staff engagement and education, and regular project evaluation. Trends of process measures and quality improvement measures were examined. An increasing trend in the rate of postoperative delirium screening during implementation of rPOD intervention was demonstrated. This quality improvement study provides a bases for future postoperative delirium reduction interventions.

Ineffective healing and treatment of foot ulcers can lead to an infection and gangrene of the wound area that ultimately results in the loss of the limb. The incidence of foot ulcers is higher in patients with diabetes, peripheral vascular disease and kidney disease. Accordingly, this study was undertaken to assess the ability of foot bathing in CO2-enriched water to heal foot ulcers. The design was a double-blinded, randomized, placebo-controlled study. Patients with at least one foot ulcer were randomized to receive either a treatment with bath therapy at 37 ± 0.5 °C containing either 1000–1200 ppm CO2-enriched tap water (the intervention) or non-carbonated tap water at 37 ± 0.5 °C (the control group). Treatment was conducted three times/week for 15 min per session for up to 16 weeks for a total of 48 treatment sessions. Before and at the end of every treatment month, wound size, wound area oxygenation and the ankle brachial index were measured. In addition, the McGill pain questionnaire was conducted. Blood was also collected at these time points (for a total of five collections) for the measurement of different biomarkers. While no significant differences (p &lt, 0.05) in the group/time interaction effect were observed, a clear separation within the wound area reduction/wound area/oxygenated Hb outcomes was seen between placebo (control) and treatment (CO2) group. This pilot study is suggestive that bathing in CO2-enriched water may accelerate the healing of foot ulcers.

Standardizing the Fried criteria (S-FC) using cutoffs specific to the patient population improves adverse outcome prediction. However, there is limited evidence to determine if a S-FC assessment can improve discrimination of cardiovascular disease (CVD) risk in middle-aged and older women.The objective of this cross-sectional analysis was to compare the ability of the Fried frailty phenotype criteria (FC) to discriminate between individuals at higher risk for CVD according to the Framingham Risk Score and Rasmussen Disease Score in comparison to the S-FC.Asper Clinical Research Institute, St. Boniface Hospital Research Centre.985 women 55 years of age or older with no previous history of CVD.Discrimination of individuals with high CVD risk according to the Framingham and Rasmussen Disease scores was assessed using receiver operating characteristic (ROC) curves, integrated discrimination index (IDI) and net reclassification index (NRI).The S-FC showed superior ability to discriminate CVD risk as assessed by area under the ROC curve (AUROC) based on the Framingham (0.728 vs 0.634, p 0.001), but not for the Rasmussen (0.594 vs 0.552, p = 0.079) risk score. Net reclassification index identified improved discrimination for both the Framingham (67.9%, p 0.001) and Rasmussen Disease scores (26.0%, p = 0.003). Integrated discrimination index also identified improved CVD risk discrimination with the Framingham (3.0%, p 0.001) and Rasmussen Disease scores (1.5%, p 0.001).In this study, the Fried frailty phenotype better discriminated cardiovascular disease risk when standardized to the study population.

Objective The associations of moderate‐vigorous physical activity (MVPA) bouts and patterns of sedentary time (ST) with frailty according to cardiovascular disease (CVD) status are unknown. Methods Accelerometry in adults ≥50 years old from the 2003‐2004 and 2005‐2006 National Health and Nutrition Examination Survey were used. Bouted and sporadic MVPA in ≥10‐minute or 0.05 for CVD interaction). Frequency of ST breaks was not associated with frailty. Average ST break intensity was protective in both groups. The duration of breaks in ST was associated with lower frailty in CVD participants only (P > 0.05 for CVD interaction). Conclusion Insufficient MVPA and prolonged ST are detrimental despite CVD status.

Background Evidence regarding the incremental benefit of cardiac resynchronization therapy (CRT) with a defibrillator (CRT‐D) versus without (CRT‐P) in elderly patients with heart failure is limited. We compared mortality and cardiac hospitalisation between CRT‐D and CRT‐P in the elderly. Methods A retrospective chart review identified all consecutive patients with age ≥75 with CRT implantation over the last 10 years at a Canadian tertiary care cardiac centre. Kaplan‐Meier survival analyses and cumulative incidence curves were used to compare mortality and time to first cardiac hospitalisation, respectively, with CRT‐D versus CRT‐P over a 3 year period. Analyses were also repeated with propensity score matching based on age, sex, primary versus secondary prevention, date of implant, and Charlson Comorbidity Index. Results One hundred and seventy CRT patients were identified. A total of 128 received CRT‐D while 42 received CRT‐P. Median age was 79 (IQR 77‐81), and the majority were male (83%). CRT‐P patients had a higher burden of comorbidities (Charlson score 7, IQR 6‐8) than CRT‐D patients (Charlson score 5, IQR 5‐7; P

Cardiac surgery patients with a prolonged ICU length of stay (prICULOS) have lower rates of functional survival following their procedure, however detailed information on their health related quality of life (HRQoL) is lacking. We sought to investigate the potential need for intervention in these high-risk patients through comprehensive HRQoL assessments in the months to year following their surgery. A prospective, observational pilot study was undertaken and cardiac surgery patients with a prICULOS (ICU length of stay of ≥5 days) were recruited. A control group was obtained through recruitment of cardiac surgery patients with an ICU length of stay of 5 days. In-person clinical or telephone survey HRQoL assessments were completed at 3-6 months and 1-year time points after their procedure. The standardized mean difference (SMD) was calculated for all study variable comparisons to quantify the standardized effect size observed between non-prICULOS and prICULOS patients. 789 cardiac procedures were performed during the study period and 89 patients experienced a prICULOS (10.7%). Of these 89 patients, 35 prICULOS patients were recruited along with 35 controls. 29 out of 35 prICULOS patients completed the study (83%). At the 3-6 month follow up the prICULOS patients had higher levels of weight loss, fear of falling, and driving deficits. At 1-year, prICULOS patients had persistent difficulties with activities of daily living and required more family and external support. This study demonstrates the need for closer follow up and intervention for cardiac surgery patients with a prICULOS who were found to have poorer mid and long-term HRQoL.

BackgroundDelirium is prevalent and underdetected among cardiac surgery patients on the postoperative ward. This study aimed to validate the 4 A's Test delirium screening tool and evaluate its accuracy both when used by research assistants and when subsequently implemented by nursing staff on the ward.MethodsThis single-center, prospective observational study evaluated the performance of the 4 A's Test administered by research assistants (phase 1) and nursing staff (phase 2). Assessments were undertaken during the patients' first 3 postoperative days on the postcardiac surgery ward along with previous routine nurse-led Confusion Assessment Method assessments. These index tests were compared with a reference standard diagnosis of delirium based on Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria. Surveys regarding delirium screening were administered to nurses pre- and postimplementation of the 4 A's Test in phase 2 of the study.ResultsIn phase 1, a total of 137 patients were enrolled, of whom 24.8% experienced delirium on the postoperative cardiac ward. The 4 A's Test had a sensitivity of 85% (95% confidence interval, 73-93) and a specificity of 90% (95% confidence interval, 85-93) compared with the reference standard. The nurse-assessed Confusion Assessment Method had a sensitivity of 23% (95% confidence interval, 13-37) and specificity of 100% (95% confidence interval, 99-100). In phase 2, nurses (n = 51) screened 179 patients for delirium using the 4 A's Test. Compared with the reference rater, the 4 A's Test had a sensitivity of 58% (95% confidence interval, 28-85) and specificity of 94% (95% confidence interval, 85-98). Postimplementation, 64% of nurses thought that the 4 A's Test improved their confidence in delirium detection, and 76% of nurses would consider routine 4 A's Test use.ConclusionsThe 4 A's Test demonstrated moderate sensitivity and high specificity to detect delirium in a real-world setting after cardiac surgery on the postoperative ward. A modified model of use with less frequent administration, along with increased engagement of the postoperative team, is recommended to improve early delirium detection on the cardiac surgery postoperative ward.

BACKGROUND Patients with complex coronary artery disease (CAD) are treated with coronary artery bypass graft surgery (CABG). Due to progressive atherosclerotic CAD, patients with previous CABG can present with an acute coronary syndrome (ACS). Robust data demonstrating prognostic benefit for revascularization over medical management in this patient population is lacking. Therefore, we evaluated patients with previous CABG presenting with ACS, to identify the long-term outcomes of repeat revascularization vs. medical management. METHODS AND RESULTS Using the Manitoba Center for Health Policy repository, we identified patients treated with CABG, who subsequently presented with ACS from January 1, 2000 to March 31, 2018. Patients were divided into 3 groups: 1) not investigated by cardiac catheterization and managed medically; investigated by cardiac catheterization and 2a) treated medically, and 2b) treated with percutaneous coronary intervention (PCI). An inverse probability treatment weighted survival in a propensity-matched cohort was calculated, 90 days post-discharge from hospital. A total of 20297 CABG patients were included. Nearly 25% of patients with previous CABG presented with an ACS at a median of 7.2 years (3.4-11.5 years) post-CABG. In propensity-matched cohorts, treatment with PCI [N=741, median age 70 years (62-77 years); 581/741 (78.4%) male] was associated with improved survival in comparison to those investigated by catheterization but treated medically [N=546, median age 71 years (62-78 years); 418/546 (76.6%) male] at 10-years of follow-up; adjusted hazard ratio HR: 0.87 (95% CI 0.77 - 0.97); p=0.02 (Table 1, Figure 1). Patients treated medically and not referred for cardiac catheterization [N=742, median age 78 years (71-84 years); 518/742 (69.8%) male] were older and had significantly higher mortality in comparison to those treated with PCI. Mortality benefit associated with PCI may be secondary to underlying coronary anatomy and severity of disease, however, we do not have individual patient level angiographic data. CONCLUSION ACS is not uncommon following CABG. Suitable patients should be revascularized given the association with improved outcomes; however, this may be accounted for by inherent differences in the patient populations and coronary anatomy. Further individual patient level data is required to identify observed mortality differences.

BACKGROUND Centres that perform percutaneous coronary intervention (PCI) have resources specialized in the care of ST-elevation myocardial infarction (STEMI) patients both during and after PCI. Due to limited hospital resources, many centres that perform PCI have adopted protocols where STEMI patients are transferred to a non-PCI capable centre following successful PCI. However, the safety of this practice is not well established. The study objective is to evaluate the clinical outcomes of the current practice of transferring patients to non-PCI capable centres following successful PCI in a single, tertiary care regional PCI centre. METHODS AND RESULTS A retrospective analysis was performed of all consecutive STEMI patients presenting to a single, regional cardiac care centre between January 2013 and December 2014. STEMI patients with high-risk features including cardiac arrest, cardiogenic shock, medical complication nof STEMI, requiring transvenous pacing, mechanical ventiliation, mechanical circulatory support or not reperfused by PCI were excluded. Patients who were unable to be linked to the Provincial Population Registry were also excluded. Patients were analyzed based on whether they were transferred to a non-PCI capable centre following PCI for ongoing post-STEMI care. Clinical presentation, comorbidities, angiographic findings, revascularization, and repatriation status data were collected from the electronic medical record and cath lab database. Study data was linked to the Research Repository at the Manitoba Centre for Health Policy for long-term clinical outcomes. Of the 1092 consecutive STEMI patients screened, 337 patients (31%) were excluded (Figure). The final study cohort (n=697) included 397 repatriated patients and 300 non-repatriated patients. The median age of the study cohort was 60 (53-70) years. Baseline characteristics are summarized in the Table. The median length of stay at the PCI-capable hospital was 139 minutes (IQR 97-235 minutes) with 84% of patients transferred within 6 hours. Inverse probability of treatment weighting (IPTW) was used to adjust for unbalanced characteristics between the two study groups. All-cause mortality (12.9% admitted vs 10.4% repatriated patients, adjusted HR 0.90, 95% CI 0.64-1.26, p=0.535) and repeat MI (11.0% admitted vs 5.4% repatriated, adjusted HR 0.71, 95% CI 0.49-1.02, p=0.06) at 5 years were not statistically significant after IPTW adjustment, respectively. CONCLUSION This analysis demonstrated that there is no increased risk of mortality or repeat MI at five years in STEMI patients who are transferred to a non-PCI capable centre following successful PCI. This suggests that early repatriation is safe and effective for low-risk STEMI patients.

This study outlines the first step toward creating the metabolite atlas of human calcified aortic valves by identifying the expression of metabolites and metabolic pathways involved at various stages of calcific aortic valve stenosis progression. Untargeted analysis identified 72 metabolites and lipids that were significantly altered (p < 0.01) across different stages of disease progression. Of these metabolites and lipids, the levels of lysophosphatidic acid were shown to correlate with faster hemodynamic progression and could select patients at risk for faster progression rate.

Background: Frailty and cardiovascular disease (CVD) share common pathophysiology in their progression. Declines in bone health often occur concomitantly with frailty and CVD. Therefore, analytes of bone metabolism may be useful biomarkers of pre-frailty and CVD risk. The aim of this study was to identify the effects of pre-frailty and CVD risk on the systemic concentrations of bone metabolism and inflammatory analytes in middle-aged and older females. Method: This case-control study is a secondary analysis of data from 1030 females with no self-reported history of CVD. Frailty was measured using the Fried Criteria, and females were stratified into low and elevated CVD risk using the Framingham risk score. Greedy matching with pre-frailty as the exposure variable identified 26 matched pairs in the low and elevated CVD risk groups for a total of 104 females. Factorial ANOVA compared differences in the log transformed concentrations of 15 bone metabolism analytes based on pre-frailty status, CVD risk, and the interaction. Results: Differences in the systemic concentrations of IL-6 (5.25 ± 14.30 vs 1.35 ± 1.74 pg/mL, p = 0.001), TNFα (1.41 ± 1.83 vs 0.89 ± 0.40 pg/mL, p = 0.06), and leptin (12628.48 ± 10472.90 vs 7562.96 ± 4972.25 pg/mL, p = 0.023) were found in elevated CVD risk status compared to low. No differences in the concentrations of bone metabolism analytes were found based on pre-frailty status, nor were any interaction effects. Conclusion: Differences were found in the concentrations of cytokines involved in bone metabolism based on CVD risk; however, no differences were found based on pre-frailty status. IL-6, TNFα, and leptin may act as biomarkers of CVD risk, but this study does not support the use of the examined analytes involved in bone metabolism as biomarkers of pre-frailty.

To determine if bouts of moderate-vigorous physical activity (MVPA) and patterns of sedentary behavior are associated with frailty.Accelerometry from community-dwelling adults ≥50 years old (n = 2317) enrolled in the 2003-04 and 2005-06 National Health and Nutrition Examination Survey were used. Bouted (≥10 min) and sporadic (10 min) durations of MVPA were analyzed based on meeting 0%, 1-49%, 50-99%, and ≥100% of physical activity guidelines (150 min/week of MVPA). Prolonged sedentary behavior were bouts lasting ≥30 min. Breaks from sedentary behavior were defined as any ≥1 min interruption in sedentary behavior. Average intensity (counts/min) and duration (minutes) during breaks were also analyzed. Frailty was measured with a 46-item frailty index.Multivariable linear regression models adjusting for age, sex, education, ethnicity, income, marital status, smoking, alcohol consumption, body mass index, total sedentary time and accelerometer wear time indicated that meeting any percentage of the activity guidelines with bouted and sporadic MVPA was associated with reduced frailty. This relationship peaked at meeting 50-99% of guidelines and was associated with a 1.5 and 2.0 point reduction in the frailty index for bouted and sporadic MVPA, respectively. Two additional prolonged sedentary behavior bouts/day were associated with an additional frailty index deficit while every additional 100 cpm in average break intensity and every 2 min in average break duration were associated with one less deficit. Total sedentary breaks were not associated with frailty.These population-level data give justification for determining if interventions which target short bouts of MVPA and interrupting prolonged, uninterrupted time spent in sedentary behaviors can treat or prevent frailty worsening.

OBJECTIVES Long-term quality of life following open surgical valve replacement is an increasingly important outcome to patients and their caregivers. This study examines non-institutionalized survival and rehospitalization within our surgical aortic valve replacement (AVR) and mitral valve replacement (MVR) populations. METHODS A retrospective single-centre study of all consecutive open surgical valve replacements between 1995 and 2014 was undertaken. Clinical data were linked to provincial administrative data for 3219 patients who underwent AVR, MVR or double (aortic and mitral) valve replacement with or without concomitant coronary artery bypass grafting (CABG). Non-institutionalized survival and cumulative incidence of rehospitalization was examined up to 15 years. RESULTS Follow-up was complete for 96.9% of the 2146 patients who underwent AVR ± CABG (66.7% of the overall cohort), 878 who underwent MVR ± CABG (27.3%) and 195 who underwent double (aortic and mitral) valve replacement ± CABG (6.0%) with a median follow-up time of 5.6 years. Overall non-institutionalized survival was 35.4% at 15 years, and the cumulative incidence of rehospitalization was 34.4%, 63.2% and 87.0% at 1, 5 and 15 years, respectively, without significant differences between valve procedure cohorts. Both non-institutionalized survival and cumulative incidence of rehospitalization improved in more recent eras, despite increasing age and comorbidities. CONCLUSIONS Non-institutionalized survival and rehospitalization data for up to 15 years suggest good functional outcomes long after surgical AVR and/or MVR. Continued improvements are seen in these metrics over the past 2 decades. This provides a unique insight into the quality of life after surgical valve replacement in the ageing demographics with valvular heart disease.

Objective This study determined whether frailty provides incremental value to the European System for Cardiac Operative Risk Evaluation II in identifying patients at risk of poor 1-year functional survival. Methods This prospective study in patients undergoing cardiac surgery defined frailty using 3 common definitions: (1) the Modified Fried Criteria; (2) the Short Physical Performance Battery; and (3) the Clinical Frailty Scale. The primary outcome was functional survival, defined as being alive at 1 year postsurgery with a health-related quality of life score greater than 60 on the EuroQol-Visual Analogue Scale. Results Of the 188 participants, 49.5%, 52.6%, and 31.9% were deemed frail according to the Modified Fried Criteria, Short Physical Performance Battery, and Clinical Frailty Scale, respectively. The median age of our cohort was 71.0 years (29.3% female). The probability of functional survival at 1 year for the entire cohort was 73.9%. After adjusting for the European System for Cardiac Operative Risk Evaluation II, patients deemed frail under the Modified Fried Criteria, Short Physical Performance Battery, and Clinical Frailty Scale had an increased odds ratio for poor functional survival of 3.44, 3.47, and 2.08, respectively. When compared with the European System for Cardiac Operative Risk Evaluation II alone, the Modified Fried Criteria, Short Physical Performance Battery, and Clinical Frailty Scale showed an absolute improvement in the discrimination slope of 6.7%, 6.5%, and 2.4% with a category-free classification improvement of 59.6%, 59.2%, and 35.1%, respectively. Conclusions Preoperative frailty was associated with a 2- to 3.5-fold higher risk of poor functional survival 1 year after cardiac surgery. The addition of frailty to the European System for Cardiac Operative Risk Evaluation II provides incremental value in identifying patients at risk of poor functional survival 1 year postsurgery, regardless of frailty definition.

Cold weather to 0°C has been implicated as a risk factor for ventricular arrhythmias and implantable cardioverter defibrillator (ICD) shocks. The effect of more extreme cold weather on the risk of ventricular arrhythmias and ICD shocks is unknown. We sought to describe the relationship between extreme cold weather and the risk of ICD shocks. We retrospectively identified patients seen at the Pacemaker and Defibrillator Clinic at St. Boniface Hospital in Winnipeg, Manitoba, Canada between 2010 and 2015 with an ICD shock. We excluded multiple shocks occurring on the same day in a single patient. We collected weather data, and evaluated the relationship between ICD shocks and weather on the same day as the shock using Negative Binomial regression. Three hundred and sixty patients experienced a total of 1,355 shocks. When excluding multiple shocks occurring in a single patient on the same day, there were 756 unique shocks. The daily high (DH) was the strongest predictor of receiving an ICD shock. Compared with the warmest days (DH above 10°C), shocks were 25% more common on the coldest days (DH below -10°C), and 8% more common on cold days (DH between -10°C and 10°C). This linear trend was statistically significant, with a p-value of 0.04. In conclusion, we found an association between extreme cold weather and ICD shocks.

Introduction Acute kidney injury (AKI) is a potentially fatal complication of cardiac surgery. The inability to predict cardiac surgery-associated AKI is a major barrier to prevention and early treatment. Current clinical risk models for the prediction of cardiac surgery-associated AKI are insufficient, particularly in patients with preexisting kidney dysfunction. Methods To identify intraoperative variables that might improve the performance of a validated clinical risk score (Cleveland Clinic Score, CCS) for the prediction of cardiac surgery-associated AKI, we conducted a prospective cohort study in 289 consecutive elective cardiac surgery patients at a tertiary care center. We compared the area under the receiver operator characteristic curve (AUC) of a base model including only the CCS with models containing additional selected intraoperative variables including mean arterial pressure, hematocrit, duration of procedure, blood transfusions, and fluid balance. AKI was defined by the Kidney Disease Improving Global Outcomes 2012 criteria. Results The CCS alone gave an AUC of 0.72 (95% confidence interval, 0.62–0.82) for postoperative AKI. Nadir intraoperative hematocrit was the only variable that improved AUC for postoperative AKI when added to the CCS (AUC = 0.78; 95% confidence interval, 0.70–0.87; P = 0.002). In the subcohort of patients without preexisting chronic kidney disease (n = 214), where the CCS underperformed (AUC, 0.60 [0.43–0.76]), the improvement with the addition of nadir hematocrit was more marked (AUC, 0.74 [0.62–0.86]). Other variables did not improve discrimination. Discussion Nadir intraoperative hematocrit is useful in improving discrimination of clinical risk scores for AKI, and may provide a target for intervention.