Management of acute aortic services during the COVID-19 pandemic: a retrospective cohort study from the Middle East.

COVID-19 created a challenging situation for cardiac surgery and associated acute care programs around the world. While non-urgent cases might be postponed, operating on life-threatening conditions, including type A aortic dissection (TAAD), must be sustained despite the ongoing pandemic. Therefore, the authors investigated the impact of the COVID-19 pandemic on their urgent aortic program. Methods: The authors included consecutive patients presenting with TAAD (n=36) in the years 2019 and 2020 [pre-pandemic period (2019; n=16) and the pandemic era (2020; n=20)] at a tertiary care centre. Patient characteristics, TAAD presenting symptoms, operative techniques, postoperative outcomes, and length of stay were determined retrospectively using chart review and were compared between both years. Results: An increase occurred in the absolute number of TAAD referrals during the pandemic era. Patients were featured by younger age of presentation (pre-pandemic group: 47.6±18.7, and the pandemic group: 50.6±16.2 years, P=0.6) in contrast to Western data but showed similar male predominance (4:1) in both groups. There was no statistical difference in baseline comorbidities between the groups. Length of hospital stay [20 (10.8-56) vs. 14.5 (8.5-53.3) days, P=0.5] and intensive care unit stay [5 (2.3-14.5) vs. 5 (3.3-9.3) days, P=0.4] were comparable between both groups. Low rates of postoperative complications were registered in both groups with no significant between-group difference. There was no significant difference in the rates of in-hospital mortality between both groups [12.5% (2) vs. 10% (2), P=0.93]. Conclusions: Compared with the pre-pandemic era (2019), there was no difference in resource utilisation and clinical outcomes of patients presenting with TAAD during the first year of COVID-19 pandemic (2020). Structural departmental re-configuration and optimal personal protective equipment utilisation warrant maintained satisfactory outcomes in critical healthcare scenarios. Future studies are required to further investigate aortic care delivery during such challenging pandemics.

Deep sternal wound infection after coronary artery bypass: How to manage?

Mediastinitis is a devastating sternal wound complication. The aim of this study was to identify the incidence, risk factors, mortality, and different treatment modalities of mediastinitis after isolated coronary artery bypass grafting. From January 2007 to May 2010, 1424 patients who underwent isolated coronary artery bypass grafting were studied retrospectively; 1398 (group 1) had no mediastinitis, and 26 (group 2) developed mediastinitis. The diagnosis and classification of mediastinitis were based on the criteria of the Center for Disease Control and Prevention and the Emory classification, respectively. Multivariate analysis showed only 4 risk factors: diabetes mellitus, obesity, prolonged postoperative intensive care unit stay, and prolonged intubation time. On univariate analysis, female sex, renal failure, and reexploration for bleeding were also significant risk factors. The incidence of mediastinitis (1.83%) and the subsequent mortality rate (7.69%) were comparable to those of previous reports. Early detection and aggressive management of mediastinitis play major roles in decreasing the related mortality and morbidity. The Emory classification with some modification is very helpful in choosing the proper treatment modality.

Clinical characteristics and outcomes of patients with acute coronary syndrome and prior coronary artery bypass grafting in a large middle eastern cohort.

BACKGROUND: Acute Coronary Syndrome (ACS) can occur in patients with prior coronary artery bypass grafting (CABG). In the Gulf Registry of acute coronary events (Gulf RACE), we identified the clinical characteristics and in-hospital outcomes of these patients. METHODS: Clinical characteristics and in-hospital outcomes for 461 ACS patients with prior CABG are compared to 7715 ACS patients without prior CABG enrolled from 64 hospitals in 6 Gulf countries over a 6-month period. RESULTS: The overall incidence of ACS with prior CABG was 5.6% out of 8176 patients. The ACS with prior CABG were older (63 vs 55 years, P<0.0001), had more history of diabetes (62.3 vs 37.6%, P <0.0001), dyslipidemia (70.3 vs 29.5%, P<0.0001), and hypertension (75.7 vs 47.8%, P<0.0001) compared with the non-CABG group. They presented more frequently with dyspnea (14.8 vs 9.5%, P<0.0005), non-ST segment elevation myocardial infarction (41.4 vs 31.6%, P<0.0001) and echocardiographic evidence of left ventricular dysfunction (49.4 vs 29.8%, P<0.0001) than ACS without prior CABG. They had a complicated in-hospital course with more recurrent ischemia (13.9 vs 9.3%, P=0.0011), heart failure (24.1 vs 15.7%), and stroke (2.2 vs 0.6%) compared with those without CABG. The in-hospital mortality rate was 5.6% in the CABG group compared with 3.5% in the ACS without prior CABG group. After adjusting for confounders, prior CABG was independently associated with recurrent ischemia and shock, more in patients presenting with ST elevation than non-ST elevation ACS. CONCLUSIONS: Patients with ACS and prior CABG are a high-risk group with poor outcomes irrespective of their older age and comorbidities. They should be identified and treated differently to improve their outcomes.