Ultra-fast track extubation protocol following cardiovascular surgery: Predictors of failure and outcomes.

OBJECTIVES: Identifying independent predictor factors of failure of ultra-fast track (UFT) extubation and to compare in-hospital outcomes with UFT extubation versus fast track (FT) extubation after cardiovascular surgery in adults. MATERIAL AND METHODS: Retrospective analysis of 1498 consecutive patients aged over 18 years-old undergoing cardiovascular surgery at a single institution. Between December 2014 and December 2016, FT extubation was used (N = 713) while, between December 2016 and December 2018, all patients were preoperatively considered suitable for UFT extubation (N = 785). In this instance, a standardized anaesthetic protocol was applied in all cases. The decision to not extubate in the operating room (OR) was based on intraoperative haemodynamic and ventilation. RESULTS: Extubation in the OR was possible in 699 (89%) patients. Significant independent predictors factors of UFT extubation failure were: preoperative NYHA class III-IV, myocardial infarction within two days prior to surgery, preoperative intra-aortic balloon counterpulsation, urgent/emergent surgery, intraoperative transfusion of platelets and intraoperative inotropic and vasopressor support. UFT extubation was associated with lower rates of cardiovascular complications such as congestive cardiac insufficiency (OR: 1,57; 95% CI: 1,13-2,19; p = 0,008) and new-onset postoperatory atrial fibrillation (OR: 1,40; 95% CI: 1,06-1,86; p = 0,020). Patient extubated in the OR presented lower risk of overall complications, shorter intensive care unit stay and higher short-term survival, although, no statistically significance was found when performing the multivariate adjustment. CONCLUSIONS: A routine immediate extubation in the OR following adult cardiovascular surgery is a feasible and safe practice, associated with low cardiovascular morbidity.

[Pseudoaneurysm as a complication of the reconstruction of the ascending aorta using valved graft: periannular dehiscence simulating severe aortic insufficiency]. / Seudoaneurisma como complicación de la reconstrucción de aorta ascendente mediante injerto valvulado: dehiscencia perianular simulando una insuficiencia aórtica severa.

The development of a pseudoaneurysms of the ascending aorta is a potential complication after composite grafts surgery for combined disorders that simultaneously affect the aortic valve and ascending aorta. Pseudoaneurysm has been reported to range from 7% to 25% of cases, and it is due to dehiscence of the suture line at anastomosis. Clinical spectrum, which depends on the location of this dehiscence varies from the totally asymptomatic patient to one with NYHA class IV heart failure, with the possibility of its clinical status rapidly worsening. We report a case of progressive haemodynamic deterioration as a consequence of a peri-annular dehiscence that led to a significant regurgitant volume from the pseudoaneurysm cavity to the left ventricle mimicking a severe aortic insufficiency. The role of echocardiography is reviewed in the diagnosis and the management of complications, as well as the necessary follow up of patients with composite aortic grafts.