ABSTRACT
BACKGROUND: While enhanced recovery after surgery (ERAS) pathways have been successfully applied for cardiac surgery, there has been limited research directly comparing ERAS protocols to ad hoc narcotic use after surgery. We hypothesized that a standardized ERAS protocol would provide similar pain management and psychoemotional outcomes while decreasing the use of opioids in the hospital and after discharge. METHODS: As part of a 7-month quality improvement project, cardiac surgery patients on a fast-tracked to extubate pathway were assigned pro re nata (PRN) narcotic pain management for 3 months (n = 49). After a 1-month ERAS protocol optimization period, a separate group of patients were given the ERAS protocol (n = 34). Clinical outcomes were gathered, and participants completed a quality of recovery survey that allowed for the assessment of pain and symptom control at four-time points after surgery. RESULTS: Among 83 participants, 66% were male and the mean age was 53 years. There were no differences in patient characteristics between PRN and ERAS groups (all p > .244). There were no differences between ERAS and PRN groups for surgery characteristics (all p > .060), inpatient outcomes (all p > .658), or after-discharge outcomes (all p > .397). Furthermore, across all time-point comparisons, there were no supported differences in patient-reported outcome and pain control between the ERAS and PRN narcotic groups (all p > .075). CONCLUSIONS: An ERAS protocol demonstrated similar patient outcomes and pain control to traditional opioid use for postoperative cardiac surgery patients. Further research is recommended to further confirm the results of this study.
Subject(s)
Cardiac Surgical Procedures , Enhanced Recovery After Surgery , Analgesics, Opioid/therapeutic use , Female , Humans , Length of Stay , Male , Middle Aged , Narcotics/therapeutic use , Pain Management/methods , Pain, Postoperative/drug therapy , Pain, Postoperative/prevention & control , Quality Improvement , Retrospective StudiesABSTRACT
OBJECTIVE: Venoarterial extracorporeal membrane oxygenation is a rescue therapy for patients in cardiogenic shock. We hypothesize that patients bridged to heart transplant with extracorporeal membrane oxygenation have decreased survival. METHODS: The United Network of Organ Sharing database was retrospectively reviewed from January 1, 1999, to March 31, 2018, for heart transplant recipients. Recipients bridged with any form of mechanical support and those without support were compared with recipients bridged with extracorporeal membrane oxygenation. The primary end point was restricted mean survival time through 16.7 years. RESULTS: Of 26,918 recipients, 15,076 required no pretransplant mechanical support (56.0%). Support patients included 9321 with left ventricular assist devices (34.6%), 53 with right ventricular assist devices (0.2%), 258 with total artificial hearts (1.0%), 686 with biventricular assist devices (2.6%), 1378 with intra-aortic balloon pumps (5.1%), and 146 who required extracorporeal membrane oxygenation (0.5%). In the first 16.7 years post-transplant, compared with recipients bridged with extracorporeal membrane oxygenation, estimated adjusted restricted mean survival time was higher in patients who required no mechanical support (16.6 months [14.0-19.4]) and patients with a left ventricular assist device (16.5 months [99% confidence interval, 13.9-19.2]), an intra-aortic balloon pump (11.2 months [8.3-14.7]), or a biventricular assist device (6.6 months [3.6-10.3]). Restricted mean survival time in patients with a right ventricular assist device or a total artificial heart was similar to patients with extracorporeal membrane oxygenation. CONCLUSIONS: Recipients bridged with extracorporeal membrane oxygenation were estimated to survive 16.6 months less than nonmechanical circulatory support recipients. Bridge to heart transplant with extracorporeal membrane oxygenation is a viable option, and these patients should be considered transplant candidates.
Subject(s)
Assisted Circulation , Extracorporeal Membrane Oxygenation , Graft Rejection/mortality , Heart Transplantation , Multiple Organ Failure , Postoperative Complications/mortality , Preoperative Care , Assisted Circulation/instrumentation , Assisted Circulation/methods , Assisted Circulation/statistics & numerical data , Extracorporeal Membrane Oxygenation/methods , Extracorporeal Membrane Oxygenation/statistics & numerical data , Female , Heart Transplantation/methods , Heart Transplantation/mortality , Heart Transplantation/statistics & numerical data , Heart-Assist Devices/classification , Heart-Assist Devices/statistics & numerical data , Humans , Intra-Aortic Balloon Pumping/statistics & numerical data , Male , Middle Aged , Multiple Organ Failure/etiology , Multiple Organ Failure/mortality , Outcome and Process Assessment, Health Care , Preoperative Care/instrumentation , Preoperative Care/methods , Retrospective Studies , Survival Rate , United States , Waiting ListsABSTRACT
INTRODUCTION: Given the known deleterious cardiac effects of brain death (BD) physiology, we hypothesized that time from cardiac donation referral to procurement (donor support time [DST]), would negatively impact cardiac transplant recipient survival. METHODS: The United Network for Organ Sharing database was queried from 2007 to 2018, identifying 22,593 donor hearts for analysis. Multivariate logistic models for 30-day and 1-year survival, as well as Cox models for overall survival and posttransplant rejection, were used to assess adjusted outcomes. RESULTS: median DST was 3 days (interquartile range: 2-5 days). Ischemic time; distance between donor and recipient hospitals; and recipient age, creatinine, waitlist time, and length of stay were adjusted predictors of survival and rejection. DST was not associated with either outcome in aggregate; however, differential association by donor race was identified, with DST in any race recipient associated with 4% higher odds of 1-year mortality (p = .001; p value for interaction .005) but only a trend towards worse overall mortality (p = .064; p value for interaction .046). CONCLUSION: Thus, duration of exposure to BD physiology may have a differential impact on recipient outcomes based on donor race, suggesting that additional research is needed on donor immunologic, socioeconomic, and healthcare access factors that may impact cardiac transplant recipient outcomes.
Subject(s)
Heart Transplantation , Tissue and Organ Procurement , Brain Death , Graft Survival , Humans , Referral and Consultation , Retrospective Studies , Tissue DonorsSubject(s)
Aorta/surgery , Marfan Syndrome/surgery , Pregnancy Complications, Cardiovascular/surgery , Aorta/pathology , Cardiovascular Surgical Procedures , Female , Humans , Marfan Syndrome/diagnosis , Marfan Syndrome/pathology , Pregnancy , Pregnancy Complications, Cardiovascular/diagnosis , Pregnancy Complications, Cardiovascular/pathology , Treatment OutcomeABSTRACT
INTRODUCTION: Marfan syndrome is a connective tissue disorder caused by mutations in the fibrillar FBN-1 gene. Aortic dissection and rupture are major causes of morbidity and mortality and are of special concern during pregnancy. MATERIALS AND METHODS: The authors report four cases of aortic root repair with preservation of the native aortic valve that have has created a discussion between cardiothoracic surgeons, obstetricians, and gynecologists regarding the best care for Marfan syndrome patients. We present these cases here with a review of the literature. RESULTS: Surgery of the aorta and valves in Marfan syndrome is less risky than in previous eras and surgical management guidelines are generally accepted. Yet, we may be unnecessarily referring women to terminate pregnancies or to avoid pregnancy. We believe there may be alternative options for these patients. CONCLUSIONS: Marfan syndrome during pregnancy can be navigated with preconception counseling, antepartum care, and close postpartum follow-up involving an appropriate multidisciplinary team.
Subject(s)
Aorta/surgery , Aortic Aneurysm/surgery , Aortic Dissection/surgery , Aortic Valve/surgery , Blood Vessel Prosthesis Implantation/methods , Marfan Syndrome/surgery , Organ Sparing Treatments/methods , Pregnancy Complications, Cardiovascular , Adult , Counseling , Female , Humans , Interdisciplinary Communication , Patient Care Team , Perinatal Care , Pregnancy , Pregnancy Outcome , Retrospective StudiesABSTRACT
BACKGROUND: Extracorporeal membrane oxygenation (ECMO), a rescue therapy for pulmonary failure, has traditionally been limited by anticoagulation requirements. Recent practice has challenged the absolute need for anticoagulation, expanding the role of ECMO to patients with higher bleeding risk. We hypothesize that mortality, bleeding, thrombotic events, and transfusions do not differ between heparin-sparing and full therapeutic anticoagulation strategies in veno-venous (VV) ECMO management. MATERIALS AND METHODS: Adult VV ECMO patients between October 2011 and May 2018 at a single center were reviewed. A heparin-sparing strategy was implemented in October 2014; we compared outcomes in an as-treated fashion. The primary end point was survival. Secondary end points included bleeding, thrombotic complications, and transfusion requirements. RESULTS: Forty VV ECMO patients were included: 17 (147 circuit-days) before and 23 (214 circuit-days) after implementation of a heparin-sparing protocol. Patients treated with heparin-sparing anticoagulation had a lower body mass index (28.5 ± 7.1 versus 38.1 ± 12.4, P = 0.01), more often required inotropic support before ECMO (82 versus 50%, P = 0.05), and had a lower mean activated clotting time (167 ± 15 versus 189 ± 15 s, P < 0.01). There were no significant differences in survival to decannulation (59 versus 83%, P = 0.16) or discharge (50 versus 72%, P = 0.20), bleeding (32 versus 33%, P = 1.0), thromboembolic events (18 versus 39%, P = 0.17), or transfusion requirements (median 1.1 versus 0.9 unit per circuit-day, P = 0.48). CONCLUSIONS: Survival, bleeding, thrombotic complications, and transfusion requirements did not differ between heparin-sparing and full therapeutic heparin strategies for management of VV ECMO. VV ECMO can be a safe option in patients with traditional contraindications to anticoagulation.
Subject(s)
Anticoagulants/adverse effects , Extracorporeal Membrane Oxygenation/statistics & numerical data , Hemorrhage/chemically induced , Heparin/adverse effects , Thrombosis/prevention & control , Adult , Contraindications, Drug , Extracorporeal Membrane Oxygenation/adverse effects , Female , Humans , Male , Middle Aged , Retrospective Studies , Thrombosis/etiology , Young AdultABSTRACT
BACKGROUND: Limited data exist that compare the predominant cardiac preservation solutions (CPSs). MATERIALS AND METHODS: The United Network for Organ Sharing database was retrospectively reviewed from January 1, 2004 to March 31, 2018, for donor hearts. Of 34,614 potential donors, 21,908 remained after applying the exclusion criteria. The CPS analyzed included saline, the University of Wisconsin (UW), cardioplegia, Celsior, and Custodiol. The primary endpoints were recipient survival and posttransplant rejection. Logistic and Cox models were used to quantify survival endpoints. RESULTS: Saline was used as the CPS in 2549 patients (12%), UW in 10,549 (48%), cardioplegia in 1307 (6%), Celsior in 5081 (23%), and Custodiol in 2422 (11%). Donor age ranged from 15 to 68 y (mean = 32.0 y, median = 30.0 y), and 71% were male. Adjusted survival probabilities of recipients whose donor hearts were procured with saline was 96% 30 d, 90% 1 y, UW: 97% 30 d, 92% 1 y, cardioplegia: 95% 30 d, 87% 1 y, Celsior: 96% 30 d, 90% 1 y, and Custodiol: 97% 30 d, 92% 1 y. When these comparisons were adjusted for donor age, sex, ethnicity, ischemic time, recipient age, sex, ethnicity, creatinine, ventricular assist device (VAD), length of stay, region and days on waiting list, cardioplegia solution was demonstrated to have a higher risk of death (30 d, 1 y, overall) and posttransplant rejection versus UW (odds ratio 1.70, P = 0.001; odds ratio 1.63, P < 0.001; hazard ratio 1.22, P < 0.001; hazard ratio 1.21, P < 0.001, respectively). CONCLUSIONS: Cardioplegia solutions for cardiac preservation are associated with a higher mortality in heart transplant recipients.
Subject(s)
Cardioplegic Solutions/adverse effects , Graft Rejection/epidemiology , Heart Failure/surgery , Organ Preservation Solutions/adverse effects , Organ Preservation/adverse effects , Adenosine/adverse effects , Adolescent , Adult , Aged , Allografts/drug effects , Allopurinol/adverse effects , Disaccharides/adverse effects , Electrolytes/adverse effects , Female , Follow-Up Studies , Glucose/adverse effects , Glutamates/adverse effects , Glutathione/adverse effects , Graft Rejection/etiology , Graft Rejection/prevention & control , Graft Survival/drug effects , Heart/drug effects , Heart Failure/mortality , Heart Transplantation/adverse effects , Histidine/adverse effects , Humans , Insulin/adverse effects , Male , Mannitol/adverse effects , Middle Aged , Organ Preservation/methods , Potassium Chloride/adverse effects , Procaine/adverse effects , Raffinose/adverse effects , Retrospective Studies , Saline Solution/adverse effects , Survival Analysis , Treatment Outcome , Young AdultABSTRACT
BACKGROUND: Reports of race-related triathlon fatalities have raised questions regarding athlete safety. OBJECTIVE: To describe death and cardiac arrest among triathlon participants. DESIGN: Case series. SETTING: United States. PARTICIPANTS: Participants in U.S. triathlon races from 1985 to 2016. MEASUREMENTS: Data on deaths and cardiac arrests were assembled from such sources as the U.S. National Registry of Sudden Death in Athletes (which uses news media, Internet searches, LexisNexis archival databases, and news clipping services) and USA Triathlon (USAT) records. Incidence of death or cardiac arrest in USAT-sanctioned races from 2006 to 2016 was calculated. RESULTS: A total of 135 sudden deaths, resuscitated cardiac arrests, and trauma-related deaths were compiled; mean (±SE) age of victims was 46.7 ± 12.4 years, and 85% were male. Most sudden deaths and cardiac arrests occurred in the swim segment (n = 90); the others occurred during bicycling (n = 7), running (n = 15), and postrace recovery (n = 8). Fifteen trauma-related deaths occurred during the bike segment. Incidence of death or cardiac arrest among USAT participants (n = 4 776 443) was 1.74 per 100 000 (2.40 in men and 0.74 in women per 100 000; P < 0.001). In men, risk increased substantially with age and was much greater for those aged 60 years and older (18.6 per 100 000 participants). Death or cardiac arrest risk was similar for short, intermediate, and long races (1.61 vs. 1.41 vs. 1.92 per 100 000 participants). At autopsy, 27 of 61 decedents (44%) had clinically relevant cardiovascular abnormalities, most frequently atherosclerotic coronary disease or cardiomyopathy. LIMITATIONS: Case identification may be incomplete and may underestimate events, particularly in the early study period. In addition, prerace medical history is unknown in most cases. CONCLUSION: Deaths and cardiac arrests during the triathlon are not rare; most have occurred in middle-aged and older men. Most sudden deaths in triathletes happened during the swim segment, and clinically silent cardiovascular disease was present in an unexpected proportion of decedents. PRIMARY FUNDING SOURCE: Minneapolis Heart Institute Foundation.
Subject(s)
Bicycling/physiology , Death, Sudden, Cardiac/epidemiology , Heart Arrest/epidemiology , Running/physiology , Swimming/physiology , Adult , Age Distribution , Bicycling/injuries , Cause of Death , Female , Humans , Incidence , Male , Middle Aged , Retrospective Studies , Sex Distribution , United StatesABSTRACT
Interest and participation in triathlon has grown rapidly over the past 20 yr and with this growth, there has been an increase in the number of new events. To maximize the safety of participation, triathlons require medical directors to plan and oversee medical care associated with event participation. Provision of proper medical care requires knowledge of staffing requirements, common triathlon medical conditions, impact of course design, communication skill, and a familiarity of administrative requirements. These guidelines serve as a tool for triathlon medical and race directors to improve race safety for athletes.
Subject(s)
Bicycling , Delivery of Health Care/organization & administration , Physician Executives , Running , Sports Medicine/organization & administration , Swimming , Anniversaries and Special Events , Humans , Practice Guidelines as TopicABSTRACT
BACKGROUND: Recent reports from triathlon and competitive open-water swimming indicate that these events have higher rates of death compared with other forms of endurance sport. The potential causal mechanism for swimming-related death is unclear. OBJECTIVE: To examine available studies on the hypothesised mechanisms of swimming-related death to determine the most likely aetiologies. MATERIAL AND METHODS: MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews (1950 to present) were searched, yielding 1950 potential results, which after title and citation reviews were reduced to 83 possible reports. Studies included discussed mechanisms of death during swimming in humans, and were Level 4 evidence or higher. RESULTS: A total of 17 studies (366 total swimmers) were included for further analysis: 5 investigating hyperthermia/hypothermia, 7 examining cardiac mechanisms and responses, and 5 determining the presence of pulmonary edema. The studies provide inconsistent and limited-quality or disease-oriented evidence that make definitive conclusions difficult. CONCLUSIONS: The available evidence is limited but may suggest that cardiac arrhythmias are the most likely aetiology of swimming-related death. While symptoms of pulmonary edema may occur during swimming, current evidence does not support swimming-induced pulmonary edema as a frequent cause of swimming-related death, nor is there evidence to link hypothermia or hyperthermia as a causal mechanism. Further higher level studies are needed.
Subject(s)
Arrhythmias, Cardiac/epidemiology , Cause of Death , Pulmonary Edema/epidemiology , Swimming , Arrhythmias, Cardiac/etiology , Humans , Pulmonary Edema/etiologyABSTRACT
We present a case of pericardial effusion due to embolization of a fragment of an inferior vena cava (IVC) filter, with subsequent perforation of the right ventricle. This is a rare and unexpected cause of pericardial effusion. Fracture or embolization of IVC filters is a relatively uncommon complication, but these events may have serious clinical implications. Although IVC filters are often placed with the intent of removal, the device in many patients is never removed. The long-term implications of IVC filter placement must be kept in mind when making decisions about device placement and subsequent removal.
Subject(s)
Atrial Fibrillation/prevention & control , Coronary Artery Bypass/adverse effects , Heptanoic Acids/therapeutic use , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Postoperative Complications/prevention & control , Pyrroles/therapeutic use , Atorvastatin , Female , Humans , MaleABSTRACT
Ectopic liver is defined as liver parenchyma situated outside the liver proper with no connection to native hepatic tissue. This rare developmental anomaly is most commonly described as an attachment to the gallbladder with an incidence <0.3%, but it has been reported in other locations within the abdomen and thorax.(2-4) Most cases are found incidentally in asymptomatic patients, but ectopic liver has been known to cause visceral or vascular obstruction.(4,5) Herein we present a unique case of ectopic liver attached by a thin stalk seemingly floating in the suprahepatic inferior vena cava.
Subject(s)
Choristoma , Liver , Vascular Diseases/diagnosis , Vena Cava, Inferior/pathology , Adult , Female , Humans , Magnetic Resonance Imaging, Cine , Tomography, X-Ray Computed , Treatment Outcome , Vascular Diseases/pathology , Vascular Surgical Procedures , Vena Cava, Inferior/diagnostic imaging , Vena Cava, Inferior/surgerySubject(s)
Atrial Fibrillation/etiology , Atrial Fibrillation/mortality , Coronary Artery Bypass/adverse effects , Coronary Artery Bypass/mortality , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis Implantation/mortality , Aortic Valve , Female , Humans , Male , Survival RateSubject(s)
Atrial Fibrillation/mortality , Coronary Artery Bypass/adverse effects , Coronary Artery Disease/surgery , Heart Valve Diseases/surgery , Heart Valve Prosthesis Implantation , Atrial Fibrillation/etiology , Atrial Fibrillation/physiopathology , Cause of Death/trends , Follow-Up Studies , Humans , Postoperative Complications , Survival Rate/trends , Sweden/epidemiology , Time FactorsSubject(s)
Atrial Fibrillation/prevention & control , Coronary Artery Bypass/methods , Heart Arrest, Induced/instrumentation , Cardiopulmonary Bypass/adverse effects , Cardiopulmonary Bypass/methods , Cold Temperature , Coronary Artery Bypass/adverse effects , Follow-Up Studies , Heart Arrest, Induced/methods , Heart Atria , Humans , Postoperative Complications/prevention & control , Treatment OutcomeABSTRACT
Atrial fibrillation (AF) is one of the most frequent complications of cardiac surgery, affecting more than one third of patients. The mechanism of this arrhythmia is believed to be reentry. The electrophysiologic substrate may be preexisting or may develop due to heterogeneity of refractoriness after surgery. Multiple perioperative factors have been proposed to contribute to the latter, including operative trauma, inflammation, elevations in atrial pressure (including that due to left ventricular diastolic dysfunction), autonomic nervous system imbalance, metabolic and electrolyte imbalances, or myocardial ischemic damage incurred during the operation. Whether ectopic beats originating in the pulmonary veins explain at least some episodes of postoperative AF, as has been shown for nonsurgical patients with the arrhythmia, is of current interest as such sites could easily be isolated at the time of surgery. The development of postoperative AF is associated with a higher risk of operative morbidity, prolonged hospitalization, and increased hospital cost compared with that in patients remaining in sinus rhythm. Many factors have been identified as being associated with postoperative AF, but the most consistent variable across studies is increasing patient age. It is speculated that age-related pathologic changes in the atrium contribute to arrhythmia susceptibility. An important modifiable risk factor for postoperative AF is the failure to resume therapy with beta-adrenergic receptor blockers after surgery. The stratification of patients who are at higher risk for AF would focus preventative strategies on patients who are most likely to benefit from such therapy. Nonetheless, since postoperative AF often develops in patients with comorbidities who are predisposed to other complications and prolonged hospitalization, it is presently unclear whether the prevention of postoperative AF will result in improved patient outcomes, particularly shorter hospitalizations.