Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS).

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.

Perioperative hemodynamic monitoring in cardiac surgery.

PURPOSE OF REVIEW: Cardiac surgery has traditionally relied upon invasive hemodynamic monitoring, including regular use of pulmonary artery catheters. More recently, there has been advancement in our understanding as well as broader adoption of less invasive alternatives. This review serves as an outline of the key perioperative hemodynamic monitoring options for cardiac surgery. RECENT FINDINGS: Recent study has revealed that the use of invasive monitoring such as pulmonary artery catheters or transesophageal echocardiography in low-risk patients undergoing low-risk cardiac surgery is of questionable benefit. Lesser invasive approaches such a pulse contour analysis or ultrasound may provide a useful alternative to assess patient hemodynamics and guide resuscitation therapy. A number of recent studies have been published to support broader indication for these evolving technologies. SUMMARY: More selective use of indwelling catheters for cardiac surgery has coincided with greater application of less invasive alternatives. Understanding the advantages and limitations of each tool allows the bedside clinician to identify which hemodynamic monitoring modality is most suitable for which patient.

Temporary mechanical circulatory support & enhancing recovery after cardiac surgery.

PURPOSE OF REVIEW: This review highlights the integration of enhanced recovery principles with temporary mechanical circulatory support associated with adult cardiac surgery. RECENT FINDINGS: Enhanced recovery elements and efforts have been associated with improvements in quality and value. Temporary mechanical circulatory support technologies have been successfully employed, improved, and the value of their proactive use to maintain hemodynamic goals and preserve long-term myocardial function is accruing. SUMMARY: Temporary mechanical circulatory support devices promise to enhance recovery by mitigating the risk of complications, such as postcardiotomy cardiogenic shock, organ dysfunction, and death, associated with adult cardiac surgery.

Remote monitoring following adult cardiac surgery: A paradigm shift?

Background: The Perfect Care (PC) initiative engages, educates, and enrolls adult cardiac surgery patients into a transformational program that includes an app for appointment scheduling, tracking biometric data and patient-reported outcomes, audiovisual visits, and messaging, paired with a digital health kit (consisting of a fitness tracker, scale, and sphygmomanometer). PC aims to reduce postoperative length of stay (LOS) as well as 30-day readmission and mortality. Methods: This was a retrospective review of patients who underwent coronary artery bypass (CAB), valve, or combined CAB and valve procedures at either of the 2 participating hospitals between April 2018 and March 2022. Patients who participated in the PC quality improvement initiative were compared to propensity-matched controls (1:1 matching). The evaluation focused on postoperative LOS and a novel composite measure comprising 30-day readmission and mortality. Results: Remote monitoring (PC) was associated with a shorter postoperative LOS, lower combined rate of 30-day readmission and mortality, and less variation compared to matched non-PC controls. Conclusions: Integrated improvements in postoperative remote monitoring of adult cardiac surgery patients may reduce time in the hospital and post-acute care facilities. Future prioritized efforts include the development of additional, personalized biometric monitoring devices, use of biometric data to augment risk assessment, and investigation of the value of remote monitoring on various patient risk profiles to address potential disparities in care.

Practice makes perfect? Institutional coronary artery bypass case volumes and outcomes.

OBJECTIVES: Older studies of coronary artery bypass grafting (CABG) institutional case volumes and outcomes reported conflicting results. We explored this association in the rapidly changing contemporary practice of American surgeons using the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. METHODS: The 2018-2019 isolated primary CABG experience in the STS Adult Cardiac Surgery Database was analysed (241 902 patients; 1014 hospitals; 2718 surgeons). Generalized Estimating Equations were used to estimate coefficients between CABG institutional case volumes and outcomes. The observed-to-expected ratios based on STS risk models were used to assess risk-adjusted operative mortality (OM), mortality/major morbidity (MM) and deep sternal wound infections (DSWI) as a function of institutional case volumes. RESULTS: The mean (standard deviation) OM, MM and DSWI rates were 2.1% (2.7), 11.1% (9.2) and 0.6% (0.5), respectively. The mean (standard deviation) institutional case volumes per study period was 239 (192); 23% and 9% of institutions performed <100 and >500 cases/study period, respectively. There was a weak negative correlation between expected mortality (R2 -0.0014), OM (R2 -0.0272), MM (R2 -0.1213) and DSWI (R2 -0.003) and institutional case volumes. CONCLUSIONS: CABG outcomes generally improve with increasing institutional case volumes. Given the large number of CABG cases performed nationally, even the documented weak correlation has the potential to appreciably decrease OM, MM and DSWI if cases are performed at higher volume institutions. Studies focusing on additional hospital and surgeon factors are warranted to further define quality improvement opportunities.

State of the art: Proceedings of the American Association for Thoracic Surgery Enhanced Recovery After Cardiac Surgery Summit.

Despite the benefits established for multiple surgical specialties, enhanced recovery after surgery has been underused in cardiac surgery. A cardiac enhanced recovery after surgery summit was convened at the 102nd American Association for Thoracic Surgery annual meeting in May 2022 for experts to convey key enhanced recovery after surgery concepts, best practices, and applicable results for cardiac surgery. Topics included implementation of enhanced recovery after surgery, prehabilitation and nutrition, rigid sternal fixation, goal-directed therapy, and multimodal pain management.

Technologic Transformation of Perioperative Cardiac Care and Outcomes.

BACKGROUND: The "Perfect Care" initiative engages, educates, and enrolls adult cardiac surgery patients into a comprehensive program that incorporates remote perioperative monitoring (RPM). This study investigated the impact of RPM on postoperative length of stay, 30-day readmission and mortality, and other outcomes. METHODS: This quality improvement project compared outcomes in 354 consecutive patients who underwent isolated coronary artery bypass and who were enrolled in RPM between July 2019 and March 2022 at 2 centers against outcomes in propensity-matched control patients from a pool of 1301 patients who underwent isolated coronary artery bypass from April 2018 to March 2022 without RPM. Data were extracted from The Society of Thoracic Surgeons Adult Cardiac Surgery Database, and outcomes were analyzed according to its definitions. RPM used perioperative standard practice routines, a digital health kit for remote monitoring, a smartphone application and platform, and nurse navigators. Propensity scores were generated with RPM as the outcome measure, and a 2:1 match was generated using a nearest-neighbor matching algorithm. RESULTS: Patients who underwent isolated coronary artery bypass and who were participating in RPM showed a statistically significant, 15.4% (1 day) reduction in postoperative length of stay (P < .0001) and a 44% reduction in 30-day readmission and mortality (P < .039) compared with matched control patients. Significantly more RPM participants were discharged directly home instead of to a facility (99.4% vs 92.0%; P < .0001). CONCLUSIONS: The RPM platform and associated efforts to engage and monitor adult cardiac surgery patients remotely is feasible, is embraced by patients and clinicians, and transforms perioperative cardiac care by significantly improving outcomes and reducing variation.

Chest Tube Management: Past, Present, and Future Directions for Developing Evidence-Based Best Practices.

In the field of modern cardiothoracic surgery, chest drainage has become ubiquitous and yet characterized by a wide variation in practice. Meanwhile, the evolution of chest drain technology has created gaps in knowledge that represent opportunities for new research to support the development of best practices in chest drain management. The chest drain is an indispensable tool in the recovery of the cardiac surgery patient. However, decisions about chest drain management-including those about type, material, number, maintenance of patency, and the timing of removal-are largely driven by tradition due to a scarcity of quality evidence. This narrative review surveys the available evidence regarding chest-drain management practices with the objective of highlighting scientific gaps, unmet needs, and opportunities for further research.

Perioperative Anemia and Transfusions and Late Mortality in Coronary Artery Bypass Patients.

BACKGROUND: Perioperative anemia and transfusions are associated with adverse operative outcomes after coronary artery bypass graft surgery (CABG). Their individual association with long-term outcomes is unclear. METHODS: Patients aged 65 years and older who had undergone CABG and were in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (n = 504,596) from 2011 to 2018 were linked to Centers for Medicare and Medicaid Service data to assess long-term survival. The association of intraoperative anemia defined by intraoperative nadir hematocrit (nHct) and red blood cell (RBC) transfusions, and their interactions, on long-term mortality were assessed with Kaplan-Meier estimates and multivariable Cox regression. Restricted cubic splines were used to explore the association between nHct as a continuous variable and long-term mortality. RESULTS: 258,398 on-pump CABG STS Adult Cardiac Surgery Database patients surviving the perioperative period were linked to Centers for Medicare and Medicaid Service claims files. Per World Health Organization criteria, 41% had preoperative anemia. Mean intraoperative nHct was 24%; RBC transfusion rate was 43.7%. Univariable analysis associated both RBC transfusion and lower nHct with worse survival. Lower nHct was only marginally associated with risk-adjusted mortality: adjusted hazard ratio (AHR) 1.04 (95% CI, 1.01-1.06) and 1.07 (95% CI, 1.00-1.14) at nHct 20% and at nHct 14%, respectively. RBC transfusion was associated with significantly higher adjusted mortality irrespective of timing of transfusion: AHR intraoperative 1.21 (95% CI, 1.18-1.27); AHR postoperative 1.26 (95% CI, 1.22-1.30); AHR both 1.46 (95% CI, 1.40-1.52) and across all levels of nHct. RBC transfusion was not associated with improved survival at any level of nHct. CONCLUSIONS: Among Medicare CABG patients, RBC transfusions were associated with increased risk-adjusted late mortality across all levels of nHct whereas intraoperative anemia was only marginally so. Tolerance of lower intraoperative nHct than currently accepted may be preferable to transfusions.

Controversies in enhanced recovery after cardiac surgery.

Advances in cardiac surgical operative techniques and myocardial protection have dramatically improved outcomes in the past two decades. An unfortunate and unintended consequence is that 80% of the preventable morbidity and mortality following cardiac surgery now originates outside of the operating room. Our hope is that a renewed emphasis on evidence-based best practice and standardized perioperative care will reduce overall morbidity and mortality and improve patient-centric care. The Perioperative Quality Initiative (POQI) and Enhanced Recovery After Surgery-Cardiac Society (ERAS® Cardiac) have identified significant evidence gaps in perioperative medicine related to cardiac surgery, defined as areas in which there is significant controversy about how best to manage patients. These five areas of focus include patient blood management, goal-directed therapy, acute kidney injury, opioid analgesic reduction, and delirium.

The STS Participant-Level, Multiprocedural Composite Measure for Adult Cardiac Surgery.

BACKGROUND: Composite performance measures for the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database participants (typically hospital departments or practice groups) are currently available only for individual procedures. To assess overall participant performance, STS has developed a composite metric encompassing the most common adult cardiac procedures. METHODS: Analyses included 1-year (July 1, 2018 to June 30, 2019) and 3-year (July 1, 2016 to June 30, 2019) time windows. Operations included isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve repair (MVr) or replacement (MVR), AVR + CABG, MVr or MVR + CABG, AVR + MVr or MVR, and AVR + (MVr or MVR) + CABG. The composite was estimated using Bayesian hierarchical models with risk-adjusted mortality and morbidity end points. Star ratings were based upon whether the 95% credible interval of a participant's score was entirely lower than (1 star), overlapping (2 star), or higher than (3 star) the STS average composite score. RESULTS: The North American procedural mix in the 3-year study cohort was as follows: 448 569 CABG, 72 067 AVR, 35 708 MVr, 29 953 MVR, 45 254 AVR + CABG, 12 247 MVr + CABG, 10 118 MVR + CABG, 3743 AVR + MVr, 6846 AVR + MVR, and 3765 AVR + (MVr or MVR) + CABG. Mortality and morbidity weightings were similar for 1- and 3-year analyses (76% and 24% [3-year]), as were composite score distributions (median, 94.7%; interquartile range, 93.6% to 95.6% [3-year]). The 3-year time frame was selected for operational use because of higher model reliability (0.81 [0.78-0.83]) and better outlier discrimination (26%, 3 star; 16%, 1 star). Risk-adjusted outcomes for 1-, 2-, and 3-star programs were 4.3%, 3.0%, and 1.8% mortality and 18.4%, 13.4%, and 9.7% morbidity, respectively. CONCLUSIONS: The STS participant-level, multiprocedural composite measure provides comprehensive, highly reliable, overall quality assessment of adult cardiac surgery practices.

The Society of Thoracic Surgeons 2021 Adult Cardiac Surgery Risk Models for Multiple Valve Operations.

BACKGROUND: The Society of Thoracic Surgeons (STS) Quality Measurement Task Force has developed risk models and composite performance measures for isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement or repair (MVRR), AVR+CABG, and MVRR+CABG. To further enhance its portfolio of risk-adjusted performance metrics, STS has developed new risk models for multiple valve operations ± CABG procedures. METHODS: Using July 2011 to June 2019 STS Adult Cardiac Surgery Database data, risk models for AVR+MVRR (n = 31,968) and AVR+MVRR+CABG (n = 12,650) were developed with the following endpoints: Operative Mortality, major morbidity (any 1 or more of the following: cardiac reoperation, deep sternal wound infection/mediastinitis, stroke, prolonged ventilation, and renal failure), and combined mortality and/or major morbidity. Data were divided into development (July 2011 to June 2017; n = 35,109) and validation (July 2017 to June 2019; n = 9509) samples. Predictors were selected by assessing model performance and clinical face validity of full and progressively more parsimonious models. Performance of the resulting models was evaluated by assessing discrimination and calibration. RESULTS: C-statistics for the overall population of multiple valve ± CABG procedures were 0.7086, 0.6734, and 0.6840 for mortality, morbidity, and combined mortality and/or morbidity in the development sample, and 0.6953, 0.6561, and 0.6634 for the same outcomes, respectively, in the validation sample. CONCLUSIONS: New STS Adult Cardiac Surgery Database risk models have been developed for multiple valve ± CABG operations, and these models will be used in subsequent STS performance metrics.

The Society of Thoracic Surgeons Coronary Artery Bypass Graft Composite Measure: 2021 Methodology Update.

BACKGROUND: The Society of Thoracic Surgeons (STS) original coronary artery bypass graft surgery (CABG) composite measure uses a 1-year analytic cohort and 98% credible intervals (CrI) to classify better than expected (3-star) performance or worse than expected (1-star) performance. As CABG volumes per STS participant (eg, hospital or practice group) have decreased, it has become more challenging to classify performance categories using this approach, especially for lower volume programs, and alternative approaches have been explored. METHODS: Among 990 STS Adult Cardiac Surgery Database participants, performance classifications for the CABG composite were studied using various analytic cohorts: 1 year (current approach, 2017); 3 years (2015 to 2017); last 450 cases within 3 years; and most recent year (2017) plus additional cases to 450 total. We also compared 98% CrI with 95% CrI (used in other STS composite measures). RESULTS: Using 3 years of data and 95% CrIs, 113 of 990 participants (11.4%) were classified 1-star and 198 (20%) 3-star. Compared with 1-year analytic cohorts and 98% CrI, the absolute and relative increases in the proportion of 3-star participants were 14 percentage points and 233% (n = 198 [20%] vs n = 59 [6%]). Corresponding changes for 1-star participants were 6.5 percentage points and 133% (n = 113 [11.4%] vs n = 48 [4.9%]). These changes were particularly notable among lower volume (fewer than 199 CABG per year) participants. Measure reliability with the 3-year, 95% CrI modification is 0.78. CONCLUSIONS: Compared with current STS CABG composite methodology, a 3-year analytic cohort and 95% CrI increases the number and proportion of better or worse than expected outliers, especially among lower-volume Adult Cardiac Surgery Database participants. This revised methodology is also now consistent with other STS procedure composites.

Failure to Rescue: A New Society of Thoracic Surgeons Quality Metric for Cardiac Surgery.

BACKGROUND: Failure to rescue (FTR) focuses on the ability to prevent death among patients who have postoperative complications. The Society of Thoracic Surgeons (STS) Quality Measurement Task Force has developed a new, risk-adjusted FTR quality metric for adult cardiac surgery. METHODS: The study population was taken from 1118 STS Adult Cardiac Surgery Database participants including patients who underwent isolated CABG, aortic valve replacement with or without CABG, or mitral valve repair or replacement with or without CABG between January 2015 and June 2019. The FTR analysis was derived from patients who had one or more of the following complications: prolonged ventilation, stroke, reoperation, and renal failure. Data were randomly split into 70% training samples (n = 89,059) and 30% validation samples (n = 38,242). Risk variables included STS predicted risk of mortality, operative procedures, and intraoperative variables (cardiopulmonary bypass and cross-clamp times, unplanned procedures, need for circulatory support, and massive transfusion). RESULTS: Overall mortality for patients undergoing any of the index operations during the study period was 2.6% (27,045 of 1,058,138), with mortality of 0.9% (8316 of 930,837), 8% (7618 of 94,918), 30.6% (8247 of 26,934), 51.9% (2661 of 5123), and 62.3% (203 of 326), respectively, among patients having none, one, two, three, or four complications. The FTR risk model calibration was excellent, as were model discrimination (c-statistic 0.806) and the Brier score (0.102). Using 95% Bayesian credible intervals, 62 participants (5.6%) performed worse and 53 (4.7%) performed better than expected. CONCLUSIONS: A new risk-adjusted FTR metric has been developed that complements existing STS performance measures. The metric specifically assesses institutional effectiveness of postoperative care, allowing hospitals to target quality improvement efforts.

Improving the prediction of long-term readmission and mortality using a novel biomarker panel.

OBJECTIVE: Several short-term readmission and mortality prediction models have been developed using clinical risk factors or biomarkers among patients undergoing coronary artery bypass graft (CABG) surgery. The use of biomarkers for long-term prediction of readmission and mortality is less well understood. Given the established association of cardiac biomarkers with short-term adverse outcomes, we hypothesized that 5-year prediction of readmission or mortality may be significantly improved using cardiac biomarkers. MATERIALS AND METHODS: Plasma biomarkers from 1149 patients discharged alive after isolated CABG surgery from eight medical centers were measured in a cohort from the Northern New England Cardiovascular Disease Study Group between 2004 and 2007. We assessed the added predictive value of a biomarker panel with a clinical model against the clinical model alone and compared the model discrimination using the area under the receiver operating characteristic (AUROC) curves. RESULTS: In our cohort, 461 (40%) patients were readmitted or died within 5 years. Long-term outcomes were predicted by applying the STS ASCERT clinical model with an AUROC of 0.69. The biomarker panel with the clinical model resulted in a significantly improved AUROC of 0.74 (p value <.0001). Across 5 years, the hazard ratio for patients in the second to fifth quintile predicted probabilities from the biomarker augmented STS ASCERT model ranged from 2.2 to 7.9 (p values <.001). CONCLUSIONS: We report that a panel of biomarkers significantly improved prediction of long-term readmission or mortality risk following CABG surgery. Our findings suggest biomarkers help clinical care teams better assess the long-term risk of readmission or mortality.