Postoperative Nosocomial COVID-19 Infection in Cardiac Surgery: An Uncommon Event With High Mortality Rate.

BACKGROUND: The COVID-19 pandemic has had a major impact on cardiac surgery patients. Significant reductions in access to surgical treatment have forced surgeons to prioritise patients and follow strict COVID-19 protocols to protect surgeons, staff, and patients. Adult cardiac surgery and the COVID-19 pandemic: aggressive infection mitigation strategies are necessary in the operating room and surgical recovery. Nosocomial infections among cardiac surgery patients have been reported and are associated with a high mortality rate. As a COVID-19 tertiary care centre and a tertiary cardiac centre, we tried to balance the need to operate on urgent cardiac cases while protecting patients and staff from COVID-19. METHODS: During the first wave of the pandemic, we performed 579 surgeries. We report findings from an outbreak of 4 nosocomial infections. RESULTS: All patients tested negative within 24 hours of surgery or admission. Three patients were positive after surgery, suggesting an overall nosocomial rate during the first wave of 0.5% (3/579). One patient admitted for evaluation tested positive during mass screening. Two of the 4 patients died after respiratory complications. No health care worker (HCW) or family member with direct contact with these patients tested positive for COVID-19. Nosocomial COVID-19 infection is uncommon when adhering to safety protocols. Although uncommon, the mortality rate is high (50%) in our series. CONCLUSIONS: As widespread vaccination of HCWs and high-risk individuals susceptible to COVID-19 is in progress, we suggest that cardiac surgery patients, when feasible, be vaccinated before surgery given this could prevent excess mortality, protect HCWs and reduce resource use.

CONTEXTE: La pandémie de COVID-19 a eu des répercussions importantes sur les patients en chirurgie cardiaque. Les réductions importantes de l'accès aux traitements chirurgicaux ont obligé les chirurgiens à classer les patients par ordre de priorité et à suivre des protocoles COVID-19 rigoureux pour protéger les chirurgiens, le personnel et les patients. En ce qui a trait à la chirurgie cardiaque chez les adultes pendant la pandémie de COVID-19, des stratégies énergiques d'atténuation des infections sont nécessaires en salle d'opération et pendant la convalescence. Des infections nosocomiales ont été signalées chez des patients de chirurgie cardiaque; elles sont associées à un taux de mortalité élevé. Comme notre centre de soins tertiaires traite à la fois des patients atteints de troubles cardiaques et des patients atteints de la COVID-19, nous avons essayé de trouver un équilibre entre la nécessité d'effectuer les opérations cardiaques urgentes et la protection des patients et du personnel contre la COVID-19. MÉTHODOLOGIE: Pendant la première vague de la pandémie, nous avons effectué 579 interventions chirurgicales. Nous rapportons les résultats d'une éclosion de quatre infections nosocomiales. RÉSULTATS: Tous les patients ont obtenu un résultat négatif au test de dépistage dans les 24 heures suivant l'intervention ou l'admission. Trois patients ont obtenu un résultat positif à ce test après l'intervention, ce qui indique un taux global d'infection nosocomiale de 0,5 % (3 / 579) au cours de la première vague. Un patient admis pour évaluation a obtenu un résultat positif au moment du dépistage de masse. Deux des quatre patients sont morts après des complications respiratoires. Aucun travailleur de la santé ou membre de la famille ayant eu un contact direct avec ces patients n'a obtenu un résultat positif au test de dépistage de la COVID-19. L'infection nosocomiale à la COVID-19 est rare quand les protocoles de sécurité sont respectés. Mais même si elle est peu fréquente, le taux de mortalité associé est élevé (50 %) dans notre série. CONCLUSIONS: Alors que la vaccination généralisée des travailleurs de la santé et des personnes à haut risque vulnérables à la COVID-19 est en cours, nous suggérons que les patients en chirurgie cardiaque soient vaccinés avant l'opération, si possible, car cela pourrait prévenir la surmortalité, protéger les travailleurs de la santé et réduire l'utilisation des ressources.

Cost of Cardiac Surgery in Frail Compared With Nonfrail Older Adults.

BACKGROUND: Frailty is a risk factor for mortality, morbidity, and prolonged length of stay after cardiac surgery, all of which are major drivers of hospitalization costs. The incremental hospitalization costs incurred in frail patients have yet to be elucidated. METHODS: Patients aged ≥ 60 years were evaluated for frailty before coronary artery bypass grafting or heart valve surgery at 2 academic centres between 2013 and 2015 as part of the McGill Frailty Registry. Total costs were summed from the date of the index surgery to the date of hospital discharge. Mutivariable linear regression was used to determine the association between preoperative frailty status and total costs after adjusting for conventional surgical risk factors. RESULTS: Among 235 patients included in the analysis, the median age was 73.0 years (interquartile range [IQR], 70.0-78.0 years) and 68 (29%) were women. The median cost was $32,742 (IQR, $23,221-$49,627) in 91 frail patients compared with $23,370 (IQR, $19,977-$29,705) in 144 nonfrail patients. Seven extreme-cost cases > $100,000 were identified, and all of the patients in these cases exhibited baseline frailty. In the multivariable model, total costs were independently associated with frailty (adjusted additional cost, $21,245; 95% confidence interval [CI], $12,418-$30,073; P < 0.001) and valve surgery (adjusted additional cost, $20,600; 95% CI, $9,661-$31,539; P < 0.001). CONCLUSIONS: Frailty is associated with a marked increase in hospitalization costs after cardiac surgery, an effect that persists after adjusting for age, sex, surgery type, and surgical risk score. Further efforts are needed to optimize care and resource use in this vulnerable population.

Long-term outcomes after transcatheter aortic valve implantation: insights on prognostic factors and valve durability from the Canadian multicenter experience.

OBJECTIVES: This study sought to evaluate the long-term outcomes after transcatheter aortic valve implantation (TAVI) in the Multicenter Canadian Experience study, with special focus on the causes and predictors of late mortality and valve durability. BACKGROUND: Very few data exist on the long-term outcomes associated with TAVI. METHODS: This was a multicenter study including 339 patients considered to be nonoperable or at very high surgical risk (mean age: 81 ± 8 years; Society of Thoracic Surgeons score: 9.8 ± 6.4%) who underwent TAVI with a balloon-expandable Edwards valve (transfemoral: 48%, transapical: 52%). Follow-up was available in 99% of the patients, and serial echocardiographic exams were evaluated in a central echocardiography core laboratory. RESULTS: At a mean follow-up of 42 ± 15 months 188 patients (55.5%) had died. The causes of late death (152 patients) were noncardiac (59.2%), cardiac (23.0%), and unknown (17.8%). The predictors of late mortality were chronic obstructive pulmonary disease (hazard ratio [HR]: 2.18, 95% confidence interval [CI]: 1.53 to 3.11), chronic kidney disease (HR: 1.08 for each decrease of 10 ml/min in estimated glomerular filtration rate, 95% CI: 1.01 to 1.19), chronic atrial fibrillation (HR: 1.44, 95% CI: 1.02 to 2.03), and frailty (HR: 1.52, 95% CI: 1.07 to 2.17). A mild nonclinically significant decrease in valve area occurred at 2-year follow-up (p < 0.01), but no further reduction in valve area was observed up to 4-year follow-up. No changes in residual aortic regurgitation and no cases of structural valve failure were observed during the follow-up period. CONCLUSIONS: Approximately one-half of the patients who underwent TAVI because of a high or prohibitive surgical risk profile had died at a mean follow-up of 3.5 years. Late mortality was due to noncardiac comorbidities in more than one-half of patients. No clinically significant deterioration in valve function was observed throughout the follow-up period.

The relationship between inotrope exposure, six-hour postoperative physiological variables, hospital mortality and renal dysfunction in patients undergoing cardiac surgery.

INTRODUCTION: Acute haemodynamic complications are common after cardiac surgery and optimal perioperative use of inotropic agents, typically guided by haemodynamic variables, remains controversial. The aim of this study was to examine the relationship of inotrope use to hospital mortality and renal dysfunction. MATERIAL AND METHODS: A retrospective cohort study of 1,326 cardiac surgery patients was carried out at two university-affiliated ICUs. Multivariable logistic regression analysis and propensity matching were performed to evaluate whether inotrope exposure was independently associated with mortality and renal dysfunction. RESULTS: Patients exposed to inotropes had a higher mortality rate than those not exposed. After adjusting for differences in Parsonnet score, left ventricular ejection fraction, perioperative intraaortic balloon pump use, bypass time, reoperation and cardiac index, inotrope exposure appeared to be independently associated with increased hospital mortality (adjusted odds ratio (OR) 2.3, 95% confidence interval (95% CI) 1.2 to 4.5) and renal dysfunction (adjusted OR 2.7, 95% CI 1.5 to 4.6). A propensity score-matched analysis similarly demonstrated that death and renal dysfunction were significantly more likely to occur in patients exposed to inotropes (P = 0.01). CONCLUSIONS: Postoperative inotrope exposure was independently associated with worse outcomes in this cohort study. Further research is needed to better elucidate the appropriate use of inotropes in cardiac surgery.

The role of pulmonary embolectomy in the treatment of acute pulmonary embolism: a literature review from 1968 to 2008.

Acute massive or submassive pulmonary embolism (PE) requires prompt diagnosis, risk-stratification and aggressive treatment. Mortality rates can rise up to 70% within the first hour of presentation and are strongly correlated with the degree of right ventricular (RV) dysfunction, cardiac arrest, and consequential congestive heart failure. While anticoagulation is universally employed, there are inadequate data to establish definitive guidelines for the management of massive PE despite the availability of multiple treatment modalities. Medical thrombolytic therapy has not been shown to significantly reduce mortality in patients with massive PE but is still widely employed, whereas surgical and catheter embolectomy are only reserved as last resort treatments for critically ill patients with hemodynamic instability, or for those who are either not candidates for or have failed thrombolysis. Following an extensive review of medical literature, we outline the treatment options for this clinical scenario while focusing on the role of surgical embolectomy. Although traditionally reserved as rescue therapy for cases of failed thrombolysis, surgical embolectomy is a safe procedure with low mortality when performed early and in a selected group of patients. Sufficient evidence exists to extend the criteria for surgical embolectomy from strictly rescue therapy to include hemodynamically stable patients with RV dysfunction. Multidisciplinary approach to this condition coupled with a meticulous surgical technique has significantly lowered the mortality associated with this surgical procedure over the last 10 years.

Cardiac surgery in octogenarians: long-term survival, functional status, living arrangements, and leisure activities.

BACKGROUND: A prospective study of survival, functional outcome, living arrangements, daily activities and leisure engagements among octogenarians up to 5 years after cardiac surgery was performed. METHODS: The study consisted of a cohort of 300 consecutive octogenarians with three interviews made at 6-month intervals for a total of 593 postoperative interviews. Functional outcomes were measured using the Barthel index and Karnofsky performance scores and divided into autonomous, semiautonomous, or dependent. Living arrangements and leisure activities within the social, physical, cognitive, and creative domains were recorded in an open-ended questionnaire. RESULTS: There were 150 men and 150 women with a mean age 82.6 years. The 30-day survival was 84.3%. Actuarial survival at 1, 3, and 5 years was 76.6%, 66.6%, and 57.8%, respectively. Among the survivors at the first interview, 2.2 years postoperatively, there were 63.9% autonomous, 31.7% semiautonomous, and 4.3% dependent patients versus at the last interview, 3.6 years postoperatively, in which there were 64.9% autonomous, 28.1% semiautonomous, and 9.2% dependent. At the first interview, 76.4% were at home, 19.2 % in a residence, and 4.3% in a supervised setting. At the third interview, 71.8% were at home, 21.2% in a residence, and 6.9% in a supervised setting. Nearly all patients were involved in leisure activities in the social (98.9%), cognitive (98.4%), and physical (93.1%) domains. At the end of the last interview, activities within the social and cognitive domains were maintained with a small decrease in the physical domain. CONCLUSIONS: Surviving octogenarians remain at home, function independently, and engage in regular leisure activities years after cardiac surgery. This information might help physicians and surgeons regarding long-term outcome of open cardiac surgery in octogenarians.

Transcatheter aortic valve implantation for the treatment of severe symptomatic aortic stenosis in patients at very high or prohibitive surgical risk: acute and late outcomes of the multicenter Canadian experience.

OBJECTIVES: The aim of this study was: 1) to evaluate the acute and late outcomes of a transcatheter aortic valve implantation (TAVI) program including both the transfemoral (TF) and transapical (TA) approaches; and 2) to determine the results of TAVI in patients deemed inoperable because of either porcelain aorta or frailty. BACKGROUND: Very few data exist on the results of a comprehensive TAVI program including both TA and TF approaches for the treatment of severe aortic stenosis in patients at very high or prohibitive surgical risk. METHODS: Consecutive patients who underwent TAVI with the Edwards valve (Edwards Lifesciences, Inc., Irvine, California) between January 2005 and June 2009 in 6 Canadian centers were included. RESULTS: A total of 345 procedures (TF: 168, TA: 177) were performed in 339 patients. The predicted surgical mortality (Society of Thoracic Surgeons risk score) was 9.8 +/- 6.4%. The procedural success rate was 93.3%, and 30-day mortality was 10.4% (TF: 9.5%, TA: 11.3%). After a median follow-up of 8 months (25th to 75th interquartile range: 3 to 14 months) the mortality rate was 22.1%. The predictors of cumulative late mortality were peri-procedural sepsis (hazard ratio [HR]: 3.49, 95% confidence interval [CI]: 1.48 to 8.28) or need for hemodynamic support (HR: 2.58, 95% CI: 1.11 to 6), pulmonary hypertension (PH) (HR: 1.88, 95% CI: 1.17 to 3), chronic kidney disease (CKD) (HR: 2.30, 95% CI: 1.38 to 3.84), and chronic obstructive pulmonary disease (COPD) (HR: 1.75, 95% CI: 1.09 to 2.83). Patients with either porcelain aorta (18%) or frailty (25%) exhibited acute outcomes similar to the rest of the study population, and porcelain aorta patients tended to have a better survival rate at 1-year follow-up. CONCLUSIONS: A TAVI program including both TF and TA approaches was associated with comparable mortality as predicted by surgical risk calculators for the treatment of patients at very high or prohibitive surgical risk, including porcelain aorta and frail patients. Baseline (PH, COPD, CKD) and peri-procedural (hemodynamic support, sepsis) factors but not the approach determined worse outcomes.

Use of negative extrathoracic pressure to improve hemodynamics after cardiac surgery.

BACKGROUND: Little attention is given to the mode of mechanical ventilation after cardiac surgery. Positive pressure ventilation with positive end-expiratory pressure (PEEP) has been shown to reduce cardiac output. We hypothesized that positive pressure ventilation with continual negative pressure applied to the chest through a cuirass would increase cardiac output in coronary artery bypass graft patients immediately after surgery. METHODS: Twenty patients with a normal left ventricular ejection fraction were studied 2 hours after coronary artery bypass graft surgery. The patients were ventilated with synchronized intermittent mandatory ventilation (SIMV) and PEEP. Hemodynamic variables and blood gases were studied using four modes of ventilation after 15 minutes in each mode: A (baseline 1) = SIMV and 5 cmH(2)O of PEEP; B = SIMV without PEEP; C = SIMV without PEEP and with continuous negative pressure applied to the thorax at -20 cmH(2)O; D (baseline 2) = SIMV and 5 cmH(2)O of PEEP. The results of the two baselines were averaged. RESULTS: All patients were hemodynamically stable during the trial. Heart rate, blood pressure, and gas exchange were not affected by the changes in ventilatory modes. With continual negative pressure, the stroke volume index and cardiac index were significantly increased relative to ventilation with SIMV and PEEP by 3.21 mL x min(-1) x m(-2) (9.0%) and 0.45 L x min(-1) x m(-2) (13.8%), respectively. Continual negative pressure also reduced venous and wedge pressure. CONCLUSIONS: Continual negative pressure attenuates the negative effects of positive pressure ventilation on cardiac output. Although the improvement in this cohort with normal ventricular function is modest, this pilot study demonstrates that the mode of ventilation may have potentially important effects on cardiac output.

Left ventricular unloading in a patient with end-stage cardiomyopathy and medically unresponsive pulmonary hypertension.

Severe, medically unresponsive pulmonary hypertension (PHT) is considered to be a contraindication for orthotopic heart transplantation (OHT). Chronic left ventricular (LV) unloading using a left ventricular assist device (LVAD) might result in reversal of the elevated pulmonary vascular resistance (PVR), allowing successful OHT in such patients. In this study, we present a patient with end-stage ischemic cardiomyopathy and fixed, elevated PVR (7.1 Wood units) who underwent implantation of a Novacor LVAD (Baxter Healthcare Corp., Deerfield, IL, U.S.A.), with a subsequent reduction in PVR to 1.2 Wood units and successful OHT eleven months post-LVAD implantation. Three years after heart transplant, the patient still leads an active life with no right heart failure. In conclusion, OHT is not contraindicated in patients with end-stage heart failure and medically unresponsive PHT in the presence of elevated left atrial pressure. Left ventricular unloading should be considered in these patients to allow reversal of the elevated PVR before OHT.

Sutureless patch technique for postinfarction left ventricular rupture.

BACKGROUND: Left ventricular free wall rupture is an uncommon but catastrophic event after myocardial infarction and is associated with a high mortality. After prompt diagnosis some patients may be salvaged with immediate surgical intervention. Surgical techniques used to seal the rupture vary, as few surgeons have experience with this pathologic process. We report our experience using a sutureless patch technique to treat this entity. METHODS: A review of 6 consecutive patients during an 8-year period who were referred to one cardiac unit with postinfarction left ventricular rupture was conducted. RESULTS: There were 3 men and 3 women with an average age of 71.8 years. All were hemodynamically unstable, and 4 were in electromechanical dissociation. Echocardiography confirmed the diagnosis in 5 patients, and cardiac catheterization had been performed in 4 before rupture. All patients were treated promptly with fluid, inotropic agents, and, if needed, cardiopulmonary resuscitation and pericardiocentesis. Resuscitation was continued in the operating room, and the myocardial tear was sealed with a generous patch of unsupported felt secured to the heart with cyanoacrylate glue. Coronary artery bypass grafting was performed in 3 patients if the anatomy was known. All patients survived to the intensive care unit. One death occurred as a result of severe neurologic injury. Five patients were discharged from the hospital, and all were alive 2 months to 7.5 years after operation. CONCLUSIONS: A sutureless patch technique for the treatment of postinfarction rupture is simple, effective, and associated with a favorable outcome.