Implementation of cardiac enhanced recovery after surgery at lausanne university hospital, our roadbook to certification.

OBJECTIVES: Enhanced Recovery After Surgery (ERAS) is a multidisciplinary, patient-centred approach aimed at expediting recovery, improving clinical outcomes, and reducing healthcare costs. Initially developed for colorectal surgery, ERAS principles have been successfully applied across various surgical specialties, including cardiac surgery. This study outlines the implementation and certification process of the ERAS program in a tertiary cardiac surgical centre within the Heart-Vessel Department at Lausanne University Hospital. METHODS: The implementation involved forming a multidisciplinary team, including cardiac surgeons, anaesthesiologists, intensivists, a cardiologist, clinical nurse specialists, and physiotherapists. The ERAS nurse coordinator played a central role in organizing meetings, promoting the program, developing protocols, and collecting data. The certification process required adherence to ERAS guidelines, structured training, and external evaluation. Key phases included pre-ERAS data collection, protocol dissemination, inclusion of the first patients, followed by analysis and full implementation. RESULTS: Achieving certification required maintaining a compliance rate of over 70% with established protocols. The process involved overcoming various barriers, such as inconsistent practices and the need for multidisciplinary collaboration. In this paper, we provide some solutions to these challenges, including team education, regular meetings, and continuous feedback loops. Preliminary data from the initial cohort showed improvement in early mobilization, opioid use, respiratory complications, and shorter hospital stays. CONCLUSIONS: The successful implementation of the ERAS program at our institution demonstrates the feasibility and benefits of a structured, multidisciplinary approach in cardiac surgery. Continuous self-assessment and adherence to guidelines are essential for sustained improvement in patient outcomes and healthcare efficiency.

Thrombocytopenia among Patients Undergoing Aortic Valve Replacement Using the Sutureless Perceval S Bioprosthesis: A Retrospective Study.

BACKGROUND: The sutureless Perceval S bioprosthesis is associated with postoperative thrombocytopenia. Our objectives were to compare the incidence, severity, and clinical implications of thrombocytopenia after aortic valve replacement (AVR) using the Perceval S or the Trifecta bioprosthesis. METHODS: Patients who underwent AVR between March 2016 and August 2019 using the Perceval or Trifecta were retrospectively included. The primary endpoint was the nadir in platelet counts within 15 days after surgery. Secondary endpoints included postoperative hemolysis and inflammatory parameters, as well as clinical and echocardiographic outcomes. RESULTS: Overall, 156 patients were included (Perceval, n = 103; Trifecta, n = 53). Preoperatively, there was no difference in platelet counts between the two groups. Postoperatively, the Perceval S bioprosthesis was associated with a greater decrease in platelet counts. The nadir was reached at Day 3 for both groups, but thrombocytopenia was more severe for the Perceval S (Perceval S vs. Trifecta, 89.2 ± 37.7 × 109/L vs. 106.5 ± 34.1 × 109/L, p = 0.01). No difference regarding lactate dehydrogenase, C-reactive protein, and white blood cells count was found. All-cause 30-day mortality rates (both valves, 2%, p = 0.98), hospital lengths of stay, and re-operation rates were similar. CONCLUSION: The Perceval S bioprosthesis was associated with more severe postoperative thrombocytopenia. This did not translate into higher short-term morbidity or mortality.

Hemodynamic oxygenator exchange-related effects during veno-venous extracorporeal membrane oxygenation for the treatment of acute SARS-CoV-2 respiratory distress syndrome.

Few patients with coronavirus disease 2019-associated severe acute respiratory distress syndrome (ARDS) require veno-venous extracorporeal membrane oxygenation (VV-ECMO). Prolonged VV-ECMO support necessitates repeated oxygenator replacement, increasing the risk for complications. Transient hypoxemia, induced by VV-ECMO stop needed for this procedure, may induce transient myocardial ischemia and acutely declining cardiac output in critically ill patients without residual pulmonary function. This is amplified by additional activation of the sympathetic nervous system (tachycardia, pulmonary vasoconstriction, and increased systemic vascular resistance). Immediate reinjection of the priming solution of the new circuit and induced acute iatrogenic anemia are other potentially reinforcing factors. The case of a critically ill patient presented here provides an instructive illustration of the hemodynamic relationships occurring during VV-ECMO support membrane oxygenator exchange.

Complex cardiac surgery in a high-risk patient with new-onset severe mitral regurgitation and aorta to right ventricular fistula after transcatheter aortic valve implantation: a case report.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is the procedure of choice for aortic stenosis in high surgical risk patients, but it is no free from complications. CASE SUMMARY: A 86-year-old patient with severe aortic stenosis underwent TAVI 3 years ago with an Edwards Sapiens valve by femoral access. In the echocardiography follow-up, an aorta-right ventricular (Ao-RV) fistula was noted with restrictive flow and no significant shunt and it was treated conservatively. Three years after TAVI, the patient underwent cardiac surgery because of worsening heart failure due to a severe degenerative mitral regurgitation with tethering of P2 due to left ventricular remodelling, a posterior jet of severe regurgitation, and left ventricular dilatation. Surgical replacement of the TAVI and aortic root with a bioprosthesis (Medtronic Freestyle) and direct closure of the fistula was performed along with the mitral valve replacement. The patient was discharged with a good clinical result and no evidence of remaining Ao-RV fistula at transthoracic echocardiography. DISCUSSION: Aorta-right ventricular fistula is a rare entity. Most reported cases arise after rupture of a congenital coronary sinus aneurism, endocarditis, trauma, and aortic valve or aortic root surgery. This is the 10th reported case after TAVI (9 after an Edwards Sapiens TAVI). Non-significant shunt can be treated conservatively but development of heart failure and death are described in significant shunts. Balloon post-dilatation and the absence of surgical calcium debridement inherent to TAVI may theoretically contribute to the development of the fistula. Surgical replacement and closure of the fistula is a therapeutic option for this entity even in high-risk patients.

Left ventricular myocardial deformation pattern, mechanical dispersion, and their relation with electrocardiogram markers in the large population-based STANISLAS cohort: insights into electromechanical coupling.

AIMS: Mechanical alterations in patients with electrical conduction abnormalities are reported to have prognostic value in patients with left ventricular asynchrony or long QT syndrome beyond electrocardiogram (ECG) variables. Whether conduction and repolarization patterns derived from ECG are associated with speckle tracking echocardiography parameters in subjects without overt cardiac disease is yet to be investigated. To report ranges of longitudinal deformation according to conduction and repolarization values in a population-based cohort. METHODS AND RESULTS: One thousand, one hundred, and forty subjects (48.6 ± 14.0 years, 47.7% men) enrolled in the fourth visit of the STANISLAS cohort (Lorraine, France) were studied. Echocardiography strain was performed in all subjects. RR, PR, QRS, and QT intervals were retrieved from digitalized 12-lead ECG. Echocardiographic data were stratified according to quartiles of QRS and QTc duration values. Full-wall global longitudinal strain (GLS) was -21.1 ± 2.5% with a mechanical dispersion (MD) value of 34 ± 12 ms. Absolute GLS value was lower in the longest QRS quartile and shortest QTc quartile (both P < 0.001). Time-to-peak of strain was not significantly different according to QRS duration although significantly higher in patients with higher QTc (P < 0.001). MD was significantly greater in patients with longer QTc (32 ± 12 ms for QTc < 396 ms vs. 36 ± 12 ms for QTc > 421 ms; P = 0.002). CONCLUSION: Longer QTc is related to increased MD and better longitudinal strain values. In a population-based setting, QRS is not associated with MD, suggesting that echocardiography-based dyssynchrony does not largely overlap with ECG-based dyssynchrony.