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@#Gastrointestinal complications after cardiac surgery are rare, but they are associated with significant morbidity and mortality. The mechanisms of gastrointestinal complications after cardiac surgery may be unique, as the abdominal cavity is not involved. This review summarizes the current evidence of the pathophysiology, clinical manifestations, risk factors, and management of gastrointestinal complications after cardiac surgery, aiming to improve the recognition of gastrointestinal complications after cardiac surgery.
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Objective To explore the risk factors affecting prognosis of critically ill patients following cardiac surgery, furthermore, to assess severity and keep alarm earlier. Methods A retrospective study was conducted. The clinical data of critically ill patients following cardiac surgery admitted to intensive care unit (ICU) of the Affiliated Hospital of Guizhou Medical University from January 1st 2014 to December 31st 2018 were enrolled. The clinical characteristics, acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) and the worst laboratory examination within 24 hours after ICU admission, and the duration of mechanical ventilation, length of ICU stay, using continuous renal replacement therapy (CRRT), accepting vasoactive agents such as norepinephrine, dopamine or dobutamine and blood products such as red blood cells, plasma or platelets were recorded. The patients were divided into survival group and dead group based on discharge prognosis, and the difference in clinical data between the two groups was compared. Binary multivariate Logistic regression analysis was used to screen the risk factors affecting the prognosis of critically ill patients following cardiac surgery, and the receiver operating characteristic (ROC) curve was plotted to analyze the predictive value of these risk factors. Results In total, 97 patients after cardiac operation were admitted to ICU during the five years. Thirty-two patients were excluded owing to age less than 16 years old, no more than 24 hours of the length of ICU stay, without the outcomes of myocardium enzymes or myocardium markers within the first 24 hours or admitted only for pacemaker. Finally, 65 patients met the criteria, with 40 survived and 25 died. Compared with survival group, APACHEⅡ scores, the level of serum uric acid, serum creatinine (SCr), cardiac troponin T (cTnT), brain natriuretic peptide (BNP), procalcitonin (PCT) and the rate of patients accepting CRRT, vasoactive agents and blood products in dead group were significantly increased with significant differences; however, there was no statistically difference in gender, age, body weight index (BMI), distribution of types of cardiac surgery, ratio of patients suffered from hypertension and diabetes, mean arterial pressure (MAP), white blood cell (WBC), coagulation, length of ICU stay, or duration of mechanical ventilation between the two groups. Binary multivariate Logistic regression analysis showed that APACHEⅡ scores [odds ratio (OR) = 1.123, 95% confidence interval (95%CI) = 1.004-1.257, P = 0.043] and cTnT (OR = 1.496, 95%CI = 1.038-2.158, P = 0.031) were the independent risk factors for prognosis of critical ill patients following cardiac surgery. ROC curve analysis showed that APACHEⅡ score and cTnT had predictive value for prognosis of critical ill patients following cardiac surgery, the best was exerted when APACHEⅡ score combined with cTnT, the area under the ROC curve (AUC) was 0.839, the joint prediction probability was 0.42, the sensitivity was 80.0%, and the specificity was 64.0%. Conclusion APACHEⅡscore and cTnT may be one of independent risk factors for prognosis of critical ill patients following cardiac surgery, and there will be far more greater predictive value when APACHEⅡ score combined with cTnT.
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Objective To compare the impact of mean lactate concentration and lactate variability on postoperative outcome after cardiac surgery and non-cardiac surgery in critical patients, and to explore the prognostic value of the first lactate and the highest lactate during the first 24 hours in intensive care unit (ICU). Methods A retrospective study was conducted. The postoperative patients of cardiac surgery and non-cardiac surgery who were transferred to ICU immediately, and who were at least 18 years old and whose ICU lengths of stay were at least 1 day, and who were admitted to ICU of the First Affiliated Hospital of Zhengzhou University from September 2014 to September 2016 were enrolled. According to the mean lactate concentration, the patients were divided into normal lactate group (0-2 mmol/L), relatively high lactate group (2-4 mmol/L), and absolute high lactate group (> 4 mmol/L), and the relationship between the mean lactate concentration and the prognosis of patients was analyzed. According to the degree of lactate variability, the patients were divided into four groups, and multivariate regression models were used to assess the risk of death in three different lactate variability groups. The value of the first lactate value and the highest lactate value during the first 24 hours in ICU were evaluated to predict the prognosis by the receiver operating characteristic (ROC) curve. Results 268 postoperative patients of cardiac surgery and 281 cases of non-cardiac surgery were selected, and the characteristic of the baseline data in the two groups was balanced. ① Mean lactate concentration and mortality in ICU: in the normal lactate group (0-2 mmol/L), there was no significant difference in mortality between the post-cardiac operative group and post-non-cardiac operative group [7.9% (14/177) vs. 6.5% (14/217), odds ratio (OR) = 1.245, 1 = 0.694]. In the relatively high lactate group (2-4 mmol/L), there was no significant difference between the two groups, either [33.3% (12/36) vs. 23.7% (9/38), OR = 1.611, 1 = 0.442]. In the absolute high lactate group (> 4 mmol/L), ICU mortality in post-non-cardiac operative group was obviously higher than that of post-cardiac operative group [69.2% (18/26) vs. 43.6% (24/55), OR = 0.344, 1 = 0.036]. ② The ranges of lactate variability per quartile (mmol·L-1·d-1) and ICU mortality risk: there was a linear relationship between lactate variability and ICU mortality in post-non-cardiac operative group, < 0.50 (reference), 0.50-0.85 (OR = 1.17, 1 = 0.87), 0.85-1.44 (OR =4.86, 1 = 0.04), > 1.44 (OR = 22.66, 1 < 0.01) , and there was a significant difference between the two groups in the high degree of variability (0.85-1.44 and > 1.44). The risk of death after cardiac surgery tended to increase, < 0.55 (reference), 0.55-1.25 (OR = 0.61, 1 = 0.61), 1.25-2.43 (OR = 3.46, 1 = 0.10), > 2.43 (OR = 12.14, 1 < 0.01), and the risk of death only showed difference in the highest degree of variation (> 2.43). ③ ROC curve showed that the area under ROC curves (AUC) of the highest lactate in 24 hours were larger than that of the first lactate in both groups, with higher sensitivity and specificity. In the post-cardiac operative group and post-non-cardiac operative group, the AUC of the highest lactate in the first 24 hours were 0.877 and 0.875, the cut-off values were 5.35 mmol/L and 5.65 mmol/L, the sensitivity were 81.4% and 67.9%, and the specificity were 93.8% and 96.1%, respectively. Conclusions Patients with post-non-cardiac operation should be more active in controlling hyperlactatemia and lactate variability. The highest lactate in the first 24 hours maybe one of the indicator for the assessment of the prognosis of the postoperative patients.
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Constrictive pericarditis after open heart surgery is a rare entity that is difficult to diagnose. There are various approaches in the surgical treatment of pericarditis. We performed a pericardiectomy on cardiopulmonary bypass via a median approach with good results. A 67-year-old man underwent mitral valve repair in 2005. He began to experience easy fatigability as well as leg edema beginning in January 2010 for which he was treated medically. The fatigability worsened in July 2012. Echocardiography at that time was unremarkable. However, CT and MRI showed pericardial thickening adjacent to the anterior, posterior, inferior, and left lateral wall of the left ventricle. Bilateral heart catheterization revealed dip and plateau and deep X, Y waves as well as end-diastolic pressure of both chambers approximately equal to the respiratory time. He was diagnosed with constrictive pericarditis and taken to surgery. The chest was entered via median sternotomy and cardiopulmonary bypass was initiated to facilitate complete resection of the pericardium. The left phrenic nerve was visualized and care was taken to avoid damage to the structure. A part of the pericardium was strongly adherent to the epicardium. We elected to perform the waffle procedure. After pericardial resection, cardiac index improved from 1.5 <i>l</i>/min/m<sup>2</sup> to 2.7 <i>l</i>/min/m<sup>2</sup>, and central venous pressure improved from 17 to 10 mmHg. Postoperatively, dip and plateau disappeared as measured via bilateral heart catheterization and diastolic failure improved. In the treatment of constrictive pericarditis, we should resect as much of the pericardium as possible. Depending on the case, this can be facilitated by median sternotomy and cardiopulmonary bypass.