Analgesic Effect and Sleep Quality of Low-Dose Dexmedetomidine in Cardiac Surgical Patients After Ultrafast-Track Extubation: A Randomized Clinical Trial.

OBJECTIVE: To compare the analgesic and sleep quality effects of dexmedetomidine infusion versus placebo in patients undergoing cardiac surgery with ultra-fast track extubation. DESIGN: The randomized, double-blind clinical trial study. SETTING: At a single academic center hospital. PARTICIPANTS: We included patients aged 25 to 65 scheduled for elective cardiac surgery under general anesthesia with cardiopulmonary bypass from October 2021 to December 2022. INTERVENTION: After immediate extubation in the operating room, the patients who were allocated at first after providing their consent to either the dexmedetomidine group (Dex) or the placebo group (Placebo) received continuous infusion of dexmedetomidine (0.2 µg/kg/h) or saline for 12 hours postoperatively. MEASUREMENTS AND MAIN RESULTS: The groups' demographic and perioperative variables were not statistically significant. Total morphine consumption in milligrams at 12 and 24 hours after administered study drug, total sleep time in hours by BIS value ≤85, and sleep quality with the Richard-Campbell Sleep Questionnaire were compared. The analysis included 22 Dex and 23 Placebo patients. The consumption of morphine was not statistically different between the Dex and Placebo groups at 12 and 24 hours (p = 0.707 and p = 0.502, respectively). The Dex group had significantly longer sleep time (8.7 h [7.8, 9.5]) than the Placebo group (5.8 h [2.9, 8.5]; p = 0.007). The Dex group also exhibited better sleep quality (7.9 [6.7, 8.7] vs 6.6 [5.2, 8.0]; p = 0.038). CONCLUSIONS: Sedation with low-dose dexmedetomidine infusion for ultra-fast track extubation following cardiac surgery enhances sleep duration and quality.

Cost-utility analysis of sutureless and rapid deployment versus conventional aortic valve replacement in patients with moderate to severe aortic stenosis in Thailand.

BACKGROUND: Sutureless and rapid deployment aortic valve replacement (SUAVR) has become an alternative to conventional aortic valve replacement (CAVR) for aortic stenosis (AS) treatment due to its advantages in reducing surgery time and improving outcomes. This study aimed to assess the cost-utility of SUAVR vs. CAVR treatment for patients with moderate to severe AS in Thailand. METHODS: A two-part constructed model was used to estimate the lifetime costs and quality-adjusted life years (QALYs) from both societal and healthcare perspectives. Data on short-term mortality, complications, cost, and utility data were obtained from the Thai population. Long-term clinical data were derived from clinical studies. Costs and QALYs were discounted annually at 3% and presented as 2022 values. The incremental cost-effectiveness ratio (ICER) was calculated to determine additional cost per QALY gained. Deterministic and probabilistic sensitivity analyses were performed. RESULTS: SUAVR treatment incurred higher costs compared with CAVR treatment from both societal (THB 1,733,355 [USD 147,897] vs THB 1,220,643 [USD 104,150]) and healthcare provider perspectives (THB 1,594,174 [USD 136,022] vs THB 1,065,460 [USD 90,910]). In addition, SUAVR treatment resulted in lower health outcomes, with 6.20 life-years (LYs) and 4.95 QALYs, while CAVR treatment achieved 6.29 LYs and 5.08 QALYs. SUAVR treatment was considered as a dominated treatment strategy using both perspectives. Sensitivity analyses indicated the significant impact of changes in utilities and long-term mortality on the model. CONCLUSION: SUAVR treatment is not a cost-effective treatment strategy compared with CAVR treatment for patients with moderate-severe AS in Thailand, as it leads to higher costs and inferior health outcomes. Other important issues related to specific patients such as those with minimally invasive surgery, those undergoing AVR with concomitant procedures, and those with calcified and small aortic root should be taken into account.

The Influence of Left Ventricular Dysfunction on The Early and Midterm Outcome in The Patients Undergoing Off Pump Coronary Artery Bypass Grafting Assessed by Propensity Matched Score Analysis.

BACKGROUND: It still remains unclear the depth of influence of left ventricular dysfunction on the recovery of patients' physical conditions in the early and midterm period following off-pump coronary artery bypass grafting (OPCAB). METHODS: From April 2011 to May 2018, 851 patients underwent OPCAB in our center. All were grouped into two groups: Those whose ejection fraction (EF) was under 35% were defined as the Low EF group (N = 158) and those who maintained EF over 35% were defined as the Faired EF group (N = 693). Preoperatively, there was significant difference in NYHA class (P < 0.001), CCS class (P = 0.038), level of creatinine (P < 0.001), and rate of establishment of IABP (P < 0.001). RESULTS: Regarding all-cause death in the early postoperative period, low EF was a not a risk factor in patients (P = 0.52) or in the matched cohort (P = 0.398); however, in the midterm, it was a significant risk factor in patients (HR 2.07, P = 0.016) and in the matched cohort (HR 2.72, P = 0.029). Overall survival at 5 years in the Low EF group was significantly inferior to that of the Faired EF group in all (67.4±4.1% and 86.1±2.9%, P = 0.001) and in the matched cohort (66.5±6.4% vs. 86.5±4.5%, P = 0.008). CONCLUSION: OPCAB seems beneficial for patients with LV dysfunction considering the early outcome, however, low EF is a significant risk factor for overall death in the midterm period.

Successful introduction of off-pump coronary artery bypass grafting in Southeastern Asian countries: A single center's experience in Thailand.

Background: Off-pump coronary artery bypass grafting has not been standardized in Southeastern Asian countries because it is technically demanding. However, this method could be suitable for economically disadvantaged institutions because it saves cost on the heart-lung machine. We summarized our results to assess the validity of our early introduction of this method. Methods: We reviewed the data from 750 patients who underwent off-pump coronary artery bypass grafting at our institution. Before the introduction of off-pump coronary artery bypass grafting, experts from Japan were enlisted to teach our surgeons technicalities of the procedure. The primary outcome was in-hospital mortality, and secondary outcomes included any major adverse cardiac or cerebrovascular event. Results: The in-hospital mortality rate was 1.5%. The rates of survival and freedom from major adverse cardiac or cerebrovascular event 3 years after the operation were 92.5% ±â€¯1.8% and 90.7% ±â€¯2.2%, respectively. In the multivariable analysis, the independent risk factors for major adverse cardiac or cerebrovascular event were chronic obstructive pulmonary disease (adjusted hazard ratio = 2.35, 95% confidence interval = 1.35-4.10, P = .003) and renal insufficiency (adjusted hazard ratio = 2.70, 95% confidence interval = 1.52-4.80, P = .001), whereas risk factors for in-hospital death were pump conversion (relative risk = 17.4, 95% confidence interval = 1.63-4.41, P < .001). Conclusion: Successful introduction of off-pump coronary artery bypass grafting provided a favorable outcome almost equal to that in high-volume centers in developed countries.

Global Post-Market Clinical Follow-up of the Treovance Stent-Graft for Endovascular Aneurysm Repair: One-Year Results From the RATIONALE Registry.

PURPOSE:: To evaluate the safety and performance of the Treovance stent-graft. METHODS:: The global, multicenter RATIONALE registry ( ClinicalTrials.gov; identifier NCT03449875) prospectively enrolled 202 patients (mean age 73.0±7.8 years; 187 men) with abdominal aortic aneurysms (AAA) suitable for endovascular aneurysm repair (EVAR) using the Treovance. The composite primary safety endpoint was site-reported all-cause mortality and major morbidity. The primary efficacy outcome was clinical success. Further outcomes evaluated included technical success; stent-graft migration, patency, and integrity; endoleak; and aneurysm size changes. RESULTS:: Technical success was 96% (194/202); 8 patients had unresolved type I endoleaks at the end of the procedure. There was no 30-day mortality and 1% major morbidity (1 myocardial infarction and 1 bowel ischemia). Clinical success at 1 year was confirmed in 194 (96%) patients; 6 of 8 patients had new/persistent endoleaks and 2 had aneurysm expansion without identified endoleak. A total of 8 (4%) reinterventions were required during the mean 13.7±3.1 months of follow-up (median 12.8). At 1 year, the Kaplan-Meier estimate for freedom from reintervention was 95.6% (95% CI 91.4% to 97.8%). Other estimates were 95.5% (95% CI 91.7% to 97.6%) for freedom from endoleak type I/III and 97.4% (95% CI 94.2% to 98.9%) for freedom from aneurysm expansion. Thirteen (6.4%) patients died; no death was aneurysm related. CONCLUSION:: The RATIONALE registry showed favorable safety and clinical performance of the Treovance stent-graft for the treatment of infrarenal AAAs in a real-world setting.