Radical sternectomy for osteomyelitis without reconstruction post-coronary artery bypass graft: 10 years on.

Radical sternectomy with sternal reconstruction using synthetic mesh or titanium plates has been described before with excellent results. However, radical removal of the sternum without reconstruction is a rare surgical treatment for complicated deep sternal wound infections (DSWI). The long-term outcome following this radical operation is not well-known due to the limited number of cases in the literature. We report on a patient 10 years after a radical sternectomy for DSWI who presented with shortness of breath. We highlight some of the anatomical and physiological changes the chest cavity may undergo and the fact that this patient had a near normal quality of life in the 10 years following the sternectomy.

Extracorporeal Membrane Oxygenation Pathway for Management of Refractory Cardiac Arrest: A Retrospective Study from A National Center of Extracorporeal Cardiopulmonary Resuscitation.

BACKGROUND: Cardiac arrest remains a critical condition with high mortality and catastrophic neurological impact. Extracorporeal cardiopulmonary resuscitation (ECPR) has been introduced as an adjunct in cardiopulmonary resuscitation modalities. However, survival with good neurological outcomes remains a major concern. This study aims to explore our early experience with ECPR and identify the factors associated with survival in patients presenting with refractory cardiac arrest. METHODS: A retrospective cohort study analyzing six-year data from a tertiary center, the country reference for ECPR. SETTING: A national center of ECPR. PARTICIPANTS: Adult patients who experienced witnessed refractory cardiopulmonary arrest and were supported by ECPR. INTERVENTIONS: ECPR for eligible patients as per local service protocol. RESULTS: Data from 87 patients were analyzed; of this cohort, 62/87 patients presented with in-hospital cardiac arrest (IHCA), and 25/87 presented with out-of-hospital cardiac arrest (OHCA). Overall survival to decannulation and hospital discharge rates were 26.4% and 25.3%, respectively. Among survivors (n=22), 19 presented with IHCA (30.6%), whilst only 3 survivors presented with OHCA (12%). A total of 15/87 (17%) patients were alive at 6-month follow-up. All survivors had good neurological function assessed as Cerebral Performance Category 1 or 2. Multivariate logistic regression to predict survival to hospital discharge showed that IHCA was the only independent predictor (Odds Ratio 5.8, p =0.042), however, this positive association disappeared after adjusting for the first left ventricular ejection fraction after resuscitation. CONCLUSION: In this study, the use of ECPR for IHCA was associated with a higher survival to discharge compared to OHCA. This study demonstrated a comparable survival rate to other established centers, particularly for IHCA. Neurological outcomes were comparable in both IHCA and OHCA survivors. However, large multicenter studies are warranted for better under-standing and improving the outcomes.

Infected Takayasu's arteritis presenting with aortic perforation.

We want to remind Physicians that unusual conditions can present in unusual ways and to keep an open mind always.

Left ventricular outflow tract cyst: What was it and where did it go?

Cyst or thrombus formation in the left ventricular outflow tract of a normal heart is very rare. We present a case of a male who presented with a major stroke and was found to have a freely mobile cystic mass in the left ventricular outflow tract, with an otherwise completely normal heart. He had some risks factors for hypercoagulability (reduced protein C activity and raised fibrinogen), but only received aspirin therapy due to his stroke severity (haemorrhagic transformation). Once his brain imaging suggested it was safe to proceed, repeat imaging showed the mass had gone, so cardiac surgery was avoided. What was it and where did it go?

The influence of intra-aortic balloon counter pulsation on central venous blood oxygen saturation.

OBJECTIVES: We aim at identifying the changes in venous blood saturation values that associates intra-aortic balloon pump (IABP) in cardiac surgery patients with reduced left ventricular function (LVF). METHODS: A retrospective observational study was conducted in a cardiothoracic intensive care unit (CTICU) in a tertiary cardiac center over 5 years in Qatar. A total of 114 patients with at least moderate impairment of LVF with ejection fraction (EF) less than 40% were enrolled. According to the association of IABP, patients were segregated into two groups with and without IABP (groups 1, 40 patients and group 2, 74 patients). Sequential arterial and venous blood gases were analyzed. The primary outcome was to analyze the changes in the central venous saturation (ScvO2) in both groups and the secondary outcome was to analyze whether these changes affect the overall outcome in terms of intensive care unit (ICU) length of stay. RESULTS: There was no significant difference between both groups with regard to age, preoperative EF, hemoglobin, and arterial oxygen saturation (SaO2) in blood gases. Patients with IABP have a higher cScvO2 when compared to the other group (71.5 ± 12.5 vs 63.5 ± 9.3, 68.3 ± 12.6 vs 60.1 ± 9.5, 62.7 ± 10.8 vs 55.63 ± 8.1, and 60.6 ± 7.6 vs 54.9 ± 8.1; p = 0.04, 0.05, 0.03, and 0.5, respectively). However, generalized estimating equations (GEE) analysis showed that compared with the participants showing that there is a decreasing trend in mean levels within the groups during follow-ups, overall difference between both groups' mean levels was not statistically significant. CONCLUSIONS: In this study, we observed that after cardiac surgeries, patients with IABP had non-significant higher ScvO2 when compared with a corresponding group with moderate impairment of LVF. Further prospective studies are required to validate these findings.

Impact of Extracorporeal Membrane Oxygenation Service on Burnout Development in Eight Intensive Care Units. A National Cross-Sectional Study.

OBJECTIVES: This study aimed at investigating the effects of an extracorporeal membrane oxygenation (ECMO) service on Burnout syndrome (BOS) development in the intensive care unit (ICU). DESIGN: The authors conducted a cross-sectional descriptive study. SETTINGS: Eight ICUs within 5 tertiary hospitals in 1 country. PARTICIPANTS: Intensive care practitioners (nurses, physicians, and respiratory therapists). INTERVENTION: Using an online questionnaire, the Maslach Burnout Inventory Human Services Survey for Medical Personnel. In addition, demographic variables, workload, salary satisfaction, and caring for COVID-19 patients were assessed. Participants were divided based on working in an ICU with ECMO (ECMO-ICU) and without (non-ECMO-ICU) ECMO service, and burnout status (burnout and no burnout). MEASUREMENTS AND MAIN RESULTS: The response rate for completing the questionnaire was 36.4% (445/1,222). Male patients represented 53.7% of the participants. The overall prevalence of burnout was 64.5%. The overall burnout prevalence did not differ between ECMO- and non-ECMO-ICU groups (64.5% and 63.7, respectively). However, personal accomplishment (PA) score was significantly lower among ECMO-ICU personnel compared with those in a non-ECMO-ICU (42.7% v 52.6, p = 0.043). Significant predictors of burnout included profession (nurse or physician), acquiring COVID-19 infection, knowing other practitioners who were infected with COVID-19, salary dissatisfaction, and extremes of workload. CONCLUSION: Burnout was equally prevalent among participants from ECMO- and non-ECMO-ICU, but PA was lower among participants in the ICU with an ECMO service. The reported high prevalence of burnout, and its predictors, requires special attention to try to reduce its occurrence.

Analysis of the Performance of Daily Cardiac Surgery Score (CASUS) in Patients with Mixed Racial Profile after Cardiac Surgery: A Single-Center Retrospective Study.

OBJECTIVE: The aim was to look at the Cardiac Surgery Score (CASUS) assessment after cardiac surgery, and compare it with the intensive care unit (ICU) mortality and morbidity, in a racially diverse group of patients, in a single center. DESIGN: Clinical retrospective study analyzing data from 319 patients over a 1-year duration. SETTING: Cardiothoracic intensive care unit (CTICU) of a tertiary care center. PARTICIPANTS: All patients who underwent cardiac surgery between January 1 and December 31, 2017. INTERVENTIONS: Review of electronic patient records. MEASUREMENTS AND RESULTS: Daily CASUS assessments (calculated on an online application and recorded on patient electronic records) were retrieved. The variables of CASUS used for the study were CASUS value on postoperative day 1 (POD1-CASUS), on death/discharge from CTICU (Dis-CASUS), mean of all CASUS values during CTICU stay (M-CASUS), and differential CASUS (Dif- CASUS) [CASUS POD 1 - CASUS on discharge]. The receiver operating characteristic (ROC) curve for the diagnostic level of POD 1-CASUS, indicating mortality, was calculated. A value of >6.5 for POD 1 CASUS had 80% sensitivity and 84% specificity, with area under the curve value 0.756 (95% confidence interval: 0.46 to 1). The mean values of POD1-CASUS (8.6 ± 6), M-CASUS (8.2 ± 5.2), and Dis-CASUS (7.8 ± 5.7) were significantly higher in cases of mortality, compared to the others. POD1-CASUS, M-CASUS, and Dis-CASUS were found to be statistically significantly elevated in patients with acute kidney injury (AKI) and postoperative stroke, and in those who were readmitted to the CTICU after initial discharge. Patients with POD1-CASUS ≥6.5 had a statistically significant association with mortality and postoperative morbidity (p < 0.05). Findings from multivariate logistic regression indicated that body mass index (BMI), ICU readmission, length of mechanical ventilation, and length of ICU stay remained associated significantly with POD1 CASUS ≥6.5. CONCLUSION: This study found that CASUS on POD 1, mean values of CASUS during CTICU stay, and CASUS at death/discharge from CTICU predicted ICU mortality after cardiac surgery in this racially diverse group. The CASUS derivatives can be used to predict unfavorable outcomes after cardiac surgery. A POD1-CASUS value of 6.5 or more could signify mortality and postoperative morbidity.

Could Selective Re-look Angiography Improve the Outcome of Cardiogenic Shock in Patients Under Veno-arterial Extracorporeal Membrane Oxygenator?

It is not well studied whether a secondary look by angiography (Re-Ang) after fixing the culprit lesion would be beneficial or not in cardiogenic shock (CS) supported by veno-arterial extracorporeal membrane oxygenator (VA-ECMO). This study was a retrospective observational one that looked at 5-year data from a single tertiary center. Patients were grouped according to the need of Re-Ang during the VA-ECMO course into 2 groups. The indications to perform Re-Ang were loss of pulse pressure, drop in ejection fraction or velocity time integral, resistant arrhythmia, or new electrocardiographic changes suggestive of ischemia. Out of 150 patients with cardiogenic shock screened, 30 patients were enrolled in our study. Re-Ang was done in 10 patients only. In 80% of them, positive findings were found in terms of new significant stenosis (3 patients), stent restenosis (1 patient), stent thrombosis (3 patients), and patent stent(s) with intervention to the remaining lesions in other vessels (1 patient). Neither successful weaning from VA-ECMO nor mortality was statistically different between both groups. Our set indications for Re-Ang were effective in finding a possible new culprit for a conceivable coronary intervention.

Intermittent levosimendan infusion in ambulatory patients with end-stage heart failure: a systematic review and meta-analysis of 984 patients.

We sought to synthesize the available evidence regarding safety and efficacy of intermittent levosimendan (LEVO) infusions in ambulatory patients with end-stage heart failure (HF). Safety and efficacy of ambulatory intermittent LEVO infusion in patients with end-stage HF are yet not established. We systematically searched MEDLINE, EMBASE, SCOPUS, Web of Science, and Cochrane databases, from inception to January 30, 2021 for studies reporting outcome of adult ambulatory patients with end-stage HF treated with intermittent LEVO infusion. Fifteen studies (8 randomized and 7 observational) comprised 984 patients (LEVO [N = 727] and controls [N = 257]) met the inclusion criteria. LEVO was associated with improved New York Heart Association (NYHA) functional class (weighted mean difference [WMD] -1.04, 95%CI: -1.70 to -0.38, p < 0.001, 5 studies, I2 = 93%), improved left ventricular (LV) ejection fraction (WMD 4.0%, 95%CI: 2.8% to 5.3%, p < 0.001, 6 studies, I2 = 9%), and reduced BNP levels (WMD -549 pg/mL, 95%CI -866 to -233, p < 0001, 3 studies, I2 = 66%). All-cause death was not different (RR 0.65, 95%CI: 0.38 to 1.093, p = 0.10, 6 studies, I2 = 0), but cardiovascular death was lower on LEVO (RR 0.34, 95%CI: 0.13 to 0.87, p = 0.02, 3 studies, I2 = 0) compared to controls. Furthermore, health-related quality of life (HRQoL) was improved alongside with reduced LV size following LEVO infusions. Major adverse events were not different between LEVO and placebo. In conclusion, intermittent LEVO infusions in ambulatory patients with end-stage HF is associated with less frequent cardiovascular death alongside with improved NYHA class, quality of life, BNP levels, and LV function. However, the current evidence is limited by heterogeneous and relatively small studies.

Fatal native aortic valve fungal endocarditis caused by Aspergillus flavus: A case report.

Fungal endocarditis is a rare condition, specifically in immunocompetent patients. Aspergillus species are the etiology in less than 30% of the cases. Moreover, Aspergillus flavus endocarditis is extremely rare and reported in only 7% of the total Aspergillus endocarditis cases. The most common predisposing factors are immunocompromised state, prosthetic valve, and previous cardiac surgery. In most cases, the diagnosis is delayed and occasionally missed. Prompt medical management combined with early surgical intervention is recommended once the diagnosis is established since the mortality rate is nearly 100% without surgical intervention. We report a rare and fatal case of native aortic valve endocarditis in a 49 years old diabetic patient who presented with fever and abdominal pain, complicated by multiple septic embolizations (splenic infarction, cerebral emboli, and limbs ischemia), and in which A. flavus was confirmed post mortem.

Right aortic arch with mirror image branching found incidentally during coronary surgery.

Right aortic arch with a left innominate (brachiocephalic) artery with mirror image branching (RAMI) is a rare congenital anomaly, and it is unusual to diagnose it in adulthood. There are very few cases of cardiac surgery being performed for acquired cardiac disease on a congenital RAMI patient. We present a patient who had an incidental finding of a RAMI anomaly found during coronary artery bypass surgery. Post-operatively computerised tomography showed both his congenital lesions and his bypass grafts.

The Effectiveness of Levosimendan on Veno-Arterial Extracorporeal Membrane Oxygenation Management and Outcome: A Systematic Review and Meta-Analysis.

OBJECTIVES: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides a temporary support system for patients with cardiogenic shock refractory to conventional medical therapies. It has been reported that levosimendan may facilitate VA-ECMO weaning and improve survival. The primary objective of this review was to examine the effect of levosimendan use on VA-ECMO weaning and mortality in critically ill patients on VA-ECMO. DESIGN: MEDLINE, EMBASE, and CENTRAL were searched. A pair of reviewers identified eligible clinical trials. Two reviewers extracted data and independently assessed the risk of bias. A random-effect model was used to combine data. The primary outcome was the success of weaning from VA-ECMO. MEASUREMENTS AND MAIN RESULTS: Seven studies of observational design, including a total of 630 patients, were selected in the final analysis. The sample size ranged from ten-to-240 patients, with a mean age between 53 and 65 years, and more than half of them underwent cardiac surgeries. The VA-ECMO durations varied between four and 11.6 days. Overall, levosimendan use was significantly associated with successful weaning compared with control (odds ratio [OR] 2.89, 95% CI, 1.53-5.46; poverall effect = 0.001); I2 = 49%). For survival, six studies (n = 617) were included in the meta-analysis involving 326 patients in the levosimendan group and 291 in the comparator group. Pooled results showed a significantly higher survival rate in the levosimendan group (OR 0.46, 95% CI, 0.30-0.71; poverall effect = 0.0004; I2 = 20%). CONCLUSIONS: Levosimendan therapy was significantly associated with successful weaning and survival benefit in patients with cardiogenic or postcardiotomy shock needing VA-ECMO support for severe cardiocirculatory compromise. To date, there is limited literature and absence of evidence from randomized trials addressing the use of levosimendan in VA-ECMO weaning. This study may be considered a hypothesis-generating research for randomized controlled trials to confirm its findings.

Intensive care outcome of left main stem disease surgery: A single center three years' experience.

BACKGROUND: Left main coronary artery (LMCA) supplies more than 80% of the left ventricle, and significant disease of this artery carries a high mortality unless intervened surgically. However, the influence of coronary artery bypass grafting (CABG) surgery on patients with LMCA disease on morbidity intensive care unit (ICU) outcomes needs to be explored. However, the impact of CABG surgery on the morbidity of the ICU population with LMCA disease is worth exploring. AIM: To determine whether LMCA disease is a definitive risk factor of prolonged ICU stay as a primary outcome and early morbidity within the ICU stay as secondary outcome. METHODS: Retrospective descriptive study with purposive sampling analyzing 399 patients who underwent isolated urgent or elective CABG. Patients were divided into 2 groups; those with LMCA disease as group 1 (75 patients) and those without LMCA disease as group 2 (324 patients). We correlated ICU outcome parameters including ICU length of stay, post-operative atrial fibrillation, acute kidney injury, re-exploration, perioperative myocardial infarction, post-operative bleeding in both groups. RESULTS: Patients with LMCA disease had a significantly higher prevalence of diabetes (43.3% vs 29%, P = 0.001). However, we did not find a statistically significant difference with regards to ICU stay, or other morbidity and mortality outcome measures. CONCLUSION: Post-operative performance of Patients with LMCA disease who underwent CABG were comparable to those without LMCA involvement. Diabetes was more prevalent in patients with LMCA disease. These findings may help in guiding decision making for future practice and stratifying the patients' care.

A tale of three pumps and a mechanical heart.

Temporary mechanical circulatory support device (tMCS) failure could qualify patients with advanced heart failure to receive a long-term solution. We report on a patient who presented with cardiorespiratory arrest that required a tMCS and developed acute type A aortic dissection. Data Sources: our case adds further evidence regarding the support of a patient with a second (or more) incidence of tMCS. This patient subsequently underwent left ventricular assist device insertion and type A aortic dissection repair, as a combined procedure, with a satisfactory outcome.

SARS-CoV-2 (COVID-19) PCR cycle threshold: can it help in the timing of urgent cardiac surgery?

BACKGROUND: The COVID-19 pandemic has resulted in a significant reduction in urgent cardiac surgery due to concerns about safety for both patients and care givers. The timing of safe cardiac surgery is yet to be clarified in the setting of COVID-19 diagnosis. METHODS: Due to the urgency of the cardiac conditions on presentation, we have operated on four patients who exhibited the spectrum of COVID-19 disease from asymptomatic to severe COVID-19 pneumonia. With the evolving knowledge about SARS-CoV-2 and its genetic determinants as well as the cycle threshold levels obtained from real-time reverse transcription polymerase chain reaction, we have attempted to develop a strategy to deal with these patients. RESULTS: All four patients underwent urgent cardiac surgery following a thorough evaluation and multidisciplinary team approach with guidance based on the virus cycle threshold values obtained by reverse transcription polymerase chain reaction. CONCLUSION: We have shown that, with thorough preparations, consideration of the significance of the cycle threshold obtained on reverse transcription polymerase chain reaction and meticulous timing, COVID-19 diagnosed patients may undergo open heart surgery safely.

Molecular and clinical roles of incretin-based drugs in patients with heart failure.

Glucagon-like peptide-1 (GLP-1) agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors produce some beneficial and deleterious effects in diabetic patients not mediated by their glycemic lowering effects, and there is a need for better understanding of the molecular basis of these effects. They possess antioxidant and anti-inflammatory effects with some direct vasodilatory action (animal and human trial data) that may indirectly influence heart failure (HF). Unlike GLP-1R agonists, signaling for HF adverse effects was observed with two DPP-4 inhibitors, saxagliptin and alogliptin. Accordingly, these drugs should be used with caution in heart failure patients.

Improving Incidence of Postoperative Atrial Fibrillation After Cardiac Surgery Using Simplified Clinical Practice Guidelines.

OBJECTIVES: Postoperative atrial fibrillation (POAF) remains a major risk after cardiac surgery. Twelve percent patients admitted to this unit postcardiac surgery experienced POAF, which led to hemodynamic instability, increased risk of stroke, and increased length of postoperative intensive care unit stay. Our aim was to decrease the incidence of POAF in the cardiothoracic intensive care unit by the end of April 2014. METHODS: Design-Retrospective data analysis. Settings-Postcardiac surgery intensive care in a tertiary hospital. PARTICIPANTS: Postcardiac surgery patients. Intervention-A clinical practice guideline (CPG) was developed to promote early prevention and to improve adherence to POAF prophylaxis recommendations. Patient's charts were our key performance indicator. Primary outcome measure-Percentage of patients who developed episodes of POAF within the first 24 hours of cardiac surgery. Process measures-compliance with the newly developed CPG and early postoperative patient assessment. Balance measure-early administration of ß-blocker. RESULTS: We were able to decrease POAF to 8% after intervention. Compliance with early assessment improved from 25% to 87%. Compliance with adherence to the CPG was 80%. Adherence to the newly developed paper form was the major challenge that could be overcome by an electronic form. We hope to decrease the incidence of POAF to 6% and develop an electronic form by the end of December 2014. CONCLUSION: This quality improvement project changed the strategy and succeeded in decreasing the incidence of POAF after cardiac surgery. It also improved early assessment of risk factors.