Mobile health vs. standard care after cardiac surgery: results of The Box 2.0 study.

AIMS: Postoperative atrial fibrillation (POAF) is a common complication of cardiac surgery, yet difficult to detect in ambulatory patients. The primary aim of this study is to investigate the effect of a mobile health (mHealth) intervention on POAF detection after cardiac surgery. METHODS AND RESULTS: We performed an observational cohort study among 730 adult patients who underwent cardiac surgery at a tertiary care hospital in The Netherlands. Of these patients, 365 patients received standard care and were included as a historical control group, undergoing surgery between December 2017 and September 2018, and 365 patients were prospectively included from November 2018 and November 2020, undergoing an mHealth intervention which consisted of blood pressure, temperature, weight, and electrocardiogram (ECG) monitoring. One physical outpatient follow-up moment was replaced by an electronic visit. All patients were requested to fill out a satisfaction and quality of life questionnaire. Mean age in the intervention group was 62 years, 275 (70.4%) patients were males. A total of 4136 12-lead ECGs were registered. In the intervention group, 61 (16.7%) patients were diagnosed with POAF vs. 25 (6.8%) patients in the control group [adjusted risk ratio (RR) of POAF detection: 2.15; 95% confidence interval (CI): 1.55-3.97]. De novo atrial fibrillation was found in 13 patients using mHealth (6.5%) vs. 4 control group patients (1.8%; adjusted RR 3.94, 95% CI: 1.50-11.27). CONCLUSION: Scheduled self-measurements with mHealth devices could increase the probability of detecting POAF within 3 months after cardiac surgery. The effect of an increase in POAF detection on clinical outcomes needs to be addressed in future research.

Use of Impella Devices for Acute Cardiogenic Shock in the Perioperative Period of Cardiac Surgery.

INTRODUCTION: The Impella ventricular support system is a device that can be inserted percutaneously or directly across the aortic valve to unload the left ventricle. The purpose of this study is to determine the role of Impella devices in patients with acute cardiogenic shock in the perioperative period of cardiac surgery. METHODS: A retrospective single-surgeon review of 11 consecutive patients who underwent placement of Impella devices in the perioperative period of cardiac surgery was performed. Patient records were evaluated for demographics, indications for placement, and postoperative outcomes. RESULTS: Impella devices were placed for refractory cardiogenic shock preoperatively in 6 patients, intraoperatively in 4 patients, and postoperatively as a rescue in 1 patient. Seven patients received Impella CP, 1 Impella RP, 1 Impella CP and RP, and 2 Impella 5.0. Additionally, 3 patients required preoperative venovenous extracorporeal membrane oxygenation (VV-ECMO), and 1 patient required intraoperative venoarterial extracorporeal membrane oxygenation (VA-ECMO). All Impella devices were removed 1 to 28 days after implantation. Length of stay in the intensive care unit stay ranged from 2 to 53 days (average 23.9±14.6). The 30-day and 1-year mortality were 0%. Ten of 11 patients were alive at 2 years. Also, 1 patient died 18 months after surgery from complications of coronavirus disease (Covid-19). Device-related complications included varying degrees> of hemolysis in 8 patients (73%) and device malfunction in 1 patient (9%). CONCLUSIONS: The Impella ventricular support system can be combined with other mechanical support devices for additional hemodynamic support. All patients demonstrated myocardial recovery with no deaths in the perioperative period and in 1-year of follow-up. Larger studies are necessary to validate these findings.

Cardiac surgeons between apprehension and ethical duty in the COVID-19 pandemic.

BACKGROUND: Cardiothoracic surgeons are facing a big challenge in their surgical practice in the era of the COVID-19 pandemic. The attitude towards performing surgery is influenced by the pandemic. Setting special recommendations for safe cardiothoracic surgery is of extreme importance. METHODS: This was an observational cross-sectional survey that included 77 Egyptian cardiothoracic surgeons. The survey consisted of a self-administered constructed questionnaire with six sections, and was delivered as a Google Forms questionnaire (https://www.google.com/forms/about) that was sent to individuals via social networks and email. RESULTS: More than 80% of Egyptian cardiothoracic surgeons believe they and their patients are at risk. Out of all participants, none had actually been infected with COVID-19 but 26% had encountered a positive COVID-19 person in their surgical team. Although 51% were testing patients before surgery, they reported 9 confirmed cases postoperatively. Computed tomography was the most recommended investigation prior to surgery (by 69%). Most had postponed elective surgeries and only one-third of all surgeons recommended performing elective surgeries cautiously with pretesting for COVID-19 and maximizing protective measures, while more than 40% recommended not performing high-risk elective surgeries. CONCLUSION: We are committed to the safety of our patients, ourselves, our staff, and our families. Planning for the new phase of reopening, whether total reopening or step-by-step reopening, should carefully consider how we should utilize our resources, respect social distancing, and prevent exposure to untested patients or health workers who might turn out to be an undetected positive case.

Surgical Approach and Management Strategies in a Pediatric Cardiovascular Surgery Clinic During the COVID-19 Outbreak.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has required changes in the management of pediatric cardiac surgery. We would like to share the patient treatment and surgical management strategies employed in our Pediatric Cardiovascular Surgery Clinic during the COVID-19 pandemic. METHODS: A total of 112 patients were followed up in our clinic between 11.03.2020 and 02.07.2020. Their mean age was 1,118 (4-5,740) days. Management and treatment were performed by our pediatric heart team (pediatric cardiac anesthetists, general pediatricians, pediatric cardiologists, pediatric cardiac surgeons, and an infectious diseases specialist). We prepared new protocols and a surveillance system specific to the pandemic to prevent in-hospital transmission and reduce postoperative mortality and morbidity; our operations were performed according to these protocols. All decisions pertaining to the operation timing and treatment strategy of our COVID-19-positive patients were made by the same team. RESULTS: During the study period, a total of 112 patients, 69 boys and 43 girls, were hospitalized in our clinic. A total of 333 COVID-19 real-time polymerase chain reaction tests were performed on patients and accompanying persons; positive results were found in three patients and two accompanying individuals. CONCLUSION: By employing new protocols and a surveillance system throughout the healthcare system, we think that early diagnosis and treatment of the pediatric congenital heart disease population, which is susceptible to infections, can continue unperturbed. This and similar approaches can increase postoperative success and prevent transmission in the pediatric population - which are frequently COVID-19 asymptomatic.

Prone positioning in extubated patients with hypoxemic respiratory failure after cardiac surgery: A retrospective study.

BACKGROUND: Hypoxemic respiratory failure is a serious complication that can occur at any stage after cardiac surgery. Prone positioning (PP) is safe and effective for patients receiving invasive ventilation after hypoxemic respiratory failure; however, few related studies have focused on its use with extubated cardiac surgery patients. Researchers recently reported beneficial effects of PP for hypoxemic patients with COVID-19 and those with moderate ARDS (acute respiratory distress syndrome,ARDS). PP may also improve oxygenation in extubated cardiac surgery patients. OBJECTIVE: In this study, we aimed to assess the safety and effectiveness of PP in extubated cardiac surgery patients to determine whether PP can improve oxygenation and respiratory status or reduce secondary intubation. METHODS: We reviewed our institutional database between August 2018 and August 2020 and identified 22 cardiac surgery patients who had undergone PP for hypoxemic respiratory failure after extubation. From the medical and nursing records, we extracted the following data recorded before PP, during PP, and after PP for each patient, arterial blood gas analyses, hemodynamic records, laboratory reports, and respiratory function training records. RESULTS: Twenty-two extubated patients underwent 74 PP. Each patient underwent a median of 3.5 (2-5) procedures, and the median duration of each PP was 10 h. PP was implemented on the 4.5th postoperative day (median). All patients were discharged from the hospital, and none died. No complications were observed. PP improved the P/F ratio (182.65 ± 60.17, 301.53 ± 61.31, and 246.76 ± 65.68, before PP, during PP, and after PP, respectively, p < 0.001). Additionally, the respiratory rate, Forced Vital Capacity (FVC) and PaCO2 also improved, and hemodynamics showed no significant change. CONCLUSION: PP may be effective and safe for treating patients who are extubated following cardiac surgery with hypoxemic respiratory failure. For these patients, PP is associated with oxygenation and respiratory condition improvements and low secondary intubation rates.

Impact of COVID-19 on Cardiothoracic Surgery: Experience of Alexandria (Egypt) Main University Hospital.

INTRODUCTION: The current coronavirus pandemic has greatly strained the limited resources that had previously maintained the sustainability of the high-cost cardiothoracic surgeries in low-income countries like Egypt. METHODS: Hospital databases and patients' records were reviewed to evaluate the impact of the pandemic on the workflow and waiting lists. Postoperative patients were contacted by telephone for follow-up, as well as preoperative patients whose operations were cancelled. Regular virtual meetings were held, and residents were asked to discuss the stresses, challenges, and their suggestions for the gradual resumption of services. Residents' logbooks were evaluated to assess the disruption of the surgical exposure compared to 2019. RESULTS: While thoracic surgeries have continued to thrive, cardiac surgeries have witnessed the worst consequences, including cancellation of all surgeries, expansion of waiting lists, patients' non-compliance with follow-up, and impaired surgical exposure of junior residents. CONCLUSION: The gradual recovery of cardiac surgery services in Alexandria (Egypt) is being carefully planned, taking into consideration the backlog of cases and the shortage of screening kits. Careful tiering and triaging of patients by a multidisciplinary team, as well as seeking alternative assessment tools for trainees, are the main lines of our action plan.

The results of cardiac surgery during the COVID-19 pandemic compared with previous years: a propensity weighted study of outcomes at six months.

OBJECTIVES: In addition to excess mortality due to COVID-19, the pandemic has been characterised by excess mortality due to non-COVID diagnoses and consistent reports of patients delaying seeking medical treatment. This study seeks to compare the outcomes of cardiac surgery during and before the COVID-19 pandemic. DESIGN: Our institutional database was interrogated retrospectively to identify all patients undergoing one of three index procedures during the first six months of the pandemic and the corresponding epochs of the previous five years. SETTING: A regional cardiothoracic centre. PARTICIPANTS: All patients undergoing surgery during weeks #13-37, 2015-2020. MAIN OUTCOME MEASURES: Propensity score weighted analysis was employed to compare the incidence of major complications (stroke, renal failure, re-ventilation), 30-day mortality, six month survival and length of hospital stay between the two groups. RESULTS: There was no difference in 30-day mortality (HR = 0.76 [95% CI 0.27-2.20], p = 0.6211), 6-month survival (HR = 0.94 [95% CI 0.44-2.01], p = 0.8809) and duration of stay (SHR = 1.00 (95% CI 0.90-1.12), p = 0.959) between the two eras. There were no differences in the incidence of major complications (weighted chi-square test: renal failure: p = 0.923, stroke: p = 0.991, new respiratory failure: p = 0.856). CONCLUSIONS: Cardiac surgery is as safe now as in the previous five years. Concerns over the transmission of COVID-19 in hospital are understandable but patients should be encouraged not to delay seeking medical attention. All involved in healthcare and the wider public should be reassured by these findings.

Distress and anxiety following postponed cardiac surgery prior to and during the COVID-19 pandemic

INTRODUCTION: Recently, the COVID-19 pandemic has caused postponements of elective cardiac surgery. We hypothesised that postponements due to the pandemic were associated with higher levels of psychological distress than prepandemic postponements. METHODS: A prospective, observational cohort study was conducted among patients in whom elective cardiac surgery was postponed. Patients who received information regarding a new date of surgery prior to the pandemic were compared with patients postponed during the pandemic without information regarding a new date of surgery. Data were collected from patient records, validated questionnaires and interviews. RESULTS: Out of 55 postponed patients, 21 experienced prepandemic postponement. No significant differences were observed between groups regarding the psychological measures before their rescheduled operation. However, patients in both groups reported high levels of anxiety and depression with > 60% indicative of potentially positive diagnoses. No differences were found in mortality across groups and no patients developed severe complications. Interviews showed that patients in the COVID-19 group felt immediate relief at postponement and engaged in a meaning-making process with respect to their ability to tolerate postponement in order to reassure themselves and their relatives. CONCLUSIONS: No significant differences were found in psychological distress between the patients of the two groups. However, both groups experienced high levels of psychological distress. It remains unknown whether these results may be extrapolated to other surgical fields.none. TRIAL REGISTRATION: not relevant. Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

COVID-19 in the Perioperative Period of Cardiovascular Surgery: the Brazilian Experience.

INTRODUCTION: We investigated the clinical course and outcomes of patients submitted to cardiovascular surgery in Brazil and who had developed symptoms/signs of coronavirus disease 2019 (COVID-19) in the perioperative period. METHODS: A retrospective multicenter study including 104 patients who were allocated in three groups according to time of positive real time reverse transcriptase-polymerase chain reaction (RT-PCR) for the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2): group 1, patients who underwent cardiac surgery > 10 days after positive RT-PCR; group 2, patients with a positive RT-PCR within 10 days before or after surgery; group 3, patients who presented positive RT-PCR > 10 days after surgery. The primary outcome was mortality and secondary outcomes were postoperative complications, intensive care unit (ICU) length of stay, and postoperative days of hospitalization. RESULTS: The three groups were similar with respect to age, the European System of Cardiac Operative Risk Evaluation score, and comorbidities, except hypertension. Postoperative complications and death were significantly higher in groups 2 and 3 than in group 1, and no significant difference between groups 2 and 3 was seen. Group 2 showed a high prevalence of surgery performed as an urgent procedure. Although no significant differences were observed in ICU length of stay, total postoperative hospitalization time was significantly higher in group 3 than in groups 1 and 2. CONCLUSION: COVID-19 affecting the postoperative period of patients who underwent cardiovascular surgery is associated with a higher rate of morbidity and mortality. Delaying procedures in RT-PCR-positive patients may help reduce risks of perioperative complications and death.

Prognostic value of SARS-CoV-2 on patients undergoing cardiac surgery.

OBJECTIVE: To analyze Italian Cardiac Surgery experience during the pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) identifying risk factors for overall mortality according to coronavirus disease 2019 (COVID-19) status. METHODS: From February 20 to May 31, 2020, 1354 consecutive adult patients underwent cardiac surgery at 22 Italian Centers; 589 (43.5%), patients came from the red zone. Based on COVID-19 status, 1306 (96.5%) were negative to SARS-CoV-2 (COVID-N), and 48 (3.5%) were positive to SARS-CoV-2 (COVID-P); among the COVID-P 11 (22.9%) and 37 (77.1%) become positive, before and after surgery, respectively. Surgical procedures were as follows: 396 (29.2%) isolated coronary artery bypass grafting (CABG), 714 (52.7%) isolated non-CABG procedures, 207 (15.3%) two associate procedures, and three or more procedures in 37 (2.7%). Heart failure was significantly predominant in group COVID-N (10.4% vs. 2.5%, p = .01). RESULTS: Overall in-hospital mortality was 1.6% (22 cases), being significantly higher in COVID-P group (10 cases, 20.8% vs. 12, 0.9%, p < .001). Multivariable analysis identified COVID-P condition as a predictor of in-hospital mortality together with emergency status. In the COVID-P subgroup, the multivariable analysis identified increasing age and low oxygen saturation at admission as risk factors for in-hospital mortality. CONCLUSION: As expected, SARS-CoV-2 infection, either before or soon after cardiac surgery significantly increases in-hospital mortality. Moreover, among COVID-19-positive patients, older age and poor oxygenation upon admission seem to be associated with worse outcomes.

Cardiac anesthesia and COVID-19 outbreak: What should we know?

The COVID-19 outbreak is public health emergency, spreads easily from human to human, and may cause acute severe respiratory syndrome. The anesthesia teams who perform this procedure are at risk aerosolization and need special consideration and safety measures. Cardiac anesthesiologist follows two aims, recognition of COVID-19 patients that need surgery and decreasing the risk of perioperative viral transmission to coworkers. An isolated operating room (negative pressure operating room for COVID-19) should be available. It is important to regulate workflow and practices, anesthesia management, healthcare, and staff. Cardiac anesthesiologist and health-care workers must be use guidelines to treat patients with COVID-19.

Sternal wound infections during the COVID-19 pandemic: an unexpected benefit.

BACKGROUND: The novel coronavirus, now termed SARS-CoV-2, has had a significant impact on cardiac surgical services globally. Although drastically reduced, our institution has maintained a significant level of cardiac surgical activity during the pandemic. Rigorous COVID-19 guidelines have been instituted to mitigate the risk of viral transmission. We observed a reduction in sternal wound infections since the institution of new perioperative surgical guidelines. METHODS: We performed a retrospective analysis of all patients who underwent cardiac surgery at our institution since a national lockdown was declared in March 2020. A retrospective analysis of all patients who underwent cardiac surgery in the 12 months preceding the national lockdown, as a baseline cohort group, was also performed. RESULTS: A total of 2600 patients (493 during the COVID-19 pandemic) were included in this study. Urgent/emergency procedures accounted for more than 60% of procedures performed during the lockdown compared to 39% previously. During the COVID-19 pandemic, there were 4 sternal wound infections with an overall incidence of 0.8%. In comparison, the incidence of sternal wound infections was significantly higher at 3.0% in the 12-month period prior to lockdown with 63 sternal wound infections (p = 0.006). CONCLUSION: This report suggests a significant role of iatrogenic causes in sternal wound infections prior to the pandemic. The strict implementation of guidelines in the perioperative period suggests that sternal wound infections can be prevented. We propose that the now widespread COVID-19 guidelines to reduce transmission risk be adapted to help reduce the incidence of sternal wound infections.

The impact of COVID-19 pandemic on congenital heart surgery practice: An alarming change in demographics.

BACKGROUND: The aim of this study is to investigate the effect of COVID-19 outbreak on congenital cardiac surgery practice in a single center. METHODS: The first case of COVID-19 in our country was seen on March 11th, 2020. The patients operated between March 11th, 2019-and March 10th, 2020 were taken as the pre-COVID group, and those operated between March 11th and May 11th, 2020 were taken as the COVID group. The data was retrospectively collected, and the two periods were compared. RESULTS: Monthly average number of cases which was 52 patients/month (626 patients in 12 months) before COVID decreased to 35 patients/month (70 patients in 2 months) during COVID periods (P < .01). During the pre-COVID period the median postoperative length of hospital stay was 3 (IQR: 1-5) days. During the COVID period, this decreased to 1 (IQR: 1-3) day (P < .01). During the pre-COVID period, the hospital expenses of 17% (8/47) of the foreign nationals were covered by their homeland. The remaining 83% (39/47) were paid from the asylum seekers' fund. The proportion of foreign nationals operated significantly decreased during the COVID period ([7%; 47/632 vs 1%; 1/70]; P = .04). No significant difference was observed in terms of STAT mortality scores and categories and postoperative results of the operations performed between the two periods. CONCLUSIONS: Congenital cardiac surgery practice can be safely maintained with restricted case volume during the pandemic period. It is alarming that patients in the deprived areas cannot access pediatric cardiac surgery and possibly other health services because of closure of the borders between countries.

Perioperative management of COVID-19 patients undergoing cardiac surgery with cardiopulmonary bypass.

Coronavirus disease 2019 (COVID-19) is a serious health concern which affects all healthcare professionals worldwide. The pandemic puts health services, including cardiac surgery units, under escalating pressure. There are significant challenges caused by this novel virus and ensuing disease that leads to great uncertainty. While it has been advocated to delay elective surgeries, most cardiac surgical patients present in a more urgent manner which elevates the critical nature for intervention, which may make the surgical decision inevitable. To date, no definitive treatments to the pandemic have been promoted. Cardiac surgical centers may experience an increasing number of COVID-19 patients in clinical practice. Preparation for managing these patients will require a change in the current modalities for perioperative care. Therefore, the goal of this report is to share our own experiences, combined with a review of the emerging literature, by highlighting principles for the adult cardiac surgery community regarding treatment of patients scheduled for surgery. The following report will recommend perioperative guidance in patient management to include safety precautions for the heart team, the conduct of extracorporeal circulation and related equipment, and covering the early period in intensive care in the context of the current pandemic.

Saudi Society for Cardiac Surgeons consensus document on COVID-19, April 1, 2020.

The COVID-19 pandemic represents an international health crisis that is challenging to all governments. Health practitioners in different fields have a duty to guide people and governments to achieve safe health practices. The Saudi Society for Cardiac Surgeons recognizes that it is difficult to establish evidence-based guidelines for safe cardiac surgery practices in such a crisis because this is an unprecedented health pandemic. So we decided to work with our colleagues in other societies by reviewing different recommendations and safe practices issued by different health organizations and scientific societies. The aim was to come up with recommendations that could guide hospitals, physicians, and other members of the healthcare team on the best available practices that are applicable to our community and that will not only ensure optimum patient care delivery but also protect healthcare workers from the risk of infection and aid the national effort in containing and managing this worldwide pandemic.