Diabetes Mellitus is an Independent Predictor of Spinal Cord Injury After Descending Thoracic and Thoracoabdominal Aneurysm Repair: Maximum Likelihood Conditional Regression in a Propensity-Score Matched Cohort.

OBJECTIVE: To discern the impact of diabetes mellitus (DM) on spinal cord injury (SCI) after open descending thoracic and thoracoabdominal aneurysm repair (DTAAAR). BACKGROUND: Compared with euglycemia, hyperglycemia, and ketosis make neurons respectively more vulnerable and more resilient to ischemia. METHODS: During the study period (1997-2021), patient who underwent DTAAAR were dichotomized according to the presence/absence of DM. The latter was investigated as predictor of our primary (SCI) and secondary [operative mortality (OM), myocardial infarction, stroke, need for tracheostomy, de novo dialysis, and survival] endpoints. Two-level risk-adjustment employed maximum likelihood conditional regression after 1:2 propensity-score matching. RESULTS: DTAAAR was performed in 934 patients. Ninety-two diabetics were matched to 184 nondiabetics. All preoperative variables had a standardized mean difference <0.1 between the matched groups. Patients with DM had higher SCI (6.5% vs. 1.6%, P 0.03) and OM (14.1% vs. 6.0%, P =0.01), while the other secondary endpoints were similar between groups in the matched sample. DM was an independent predictor for SCI in the matched sample (odds ratio: 5.05, 95% confidence interval: 1.17-21.71). Matched patients with DM presented decreased survival at 1 (70.2% vs. 86.2%), 5 (50.4% vas 67.5%), 10 years (31.7% vs. 36.7%) ( P =0.03). The results are summarized in the graphical abstract. CONCLUSION: DM is associated to increased OM and decreased survival, and it is an independent predictor of SCI after open DTAAAR. Strict perioperative glycemic control should be implemented, and exogenous ketones should be investigated as neuroprotective agents to reduce such adverse events.

Patient care in rapid-expansion intensive care units during the COVID-19 pandemic crisis.

BACKGROUND: The coronavirus-2019 (COVID-19) pandemic highlighted the unfortunate reality that many hospitals have insufficient intensive care unit (ICU) capacity to meet massive, unanticipated increases in demand. To drastically increase ICU capacity, NewYork-Presbyterian/Weill Cornell Medical Center modified its existing operating rooms and post-anaesthesia care units during the initial expansion phase to accommodate the surge of critically ill patients. METHODS: This retrospective chart review examined patient care in non-standard Expansion ICUs as compared to standard ICUs. We compared clinical data between the two settings to determine whether the expeditious development and deployment of critical care resources during an evolving medical crisis could provide appropriate care. RESULTS: Sixty-six patients were admitted to Expansion ICUs from March 1st to April 30th, 2020 and 343 were admitted to standard ICUs. Most patients were male (70%), White (30%), 45-64 years old (35%), non-smokers (73%), had hypertension (58%), and were hospitalized for a median of 40 days. For patients that died, there was no difference in treatment management, but the Expansion cohort had a higher median ICU length of stay (q = 0.037) and ventilatory length (q = 0.015). The cohorts had similar rates of discharge to home, but the Expansion ICU cohort had higher rates of discharge to a rehabilitation facility and overall lower mortality. CONCLUSIONS: We found no significantly worse outcomes for the Expansion ICU cohort compared to the standard ICU cohort at our institution during the COVID-19 pandemic, which demonstrates the feasibility of providing safe and effective care for patients in an Expansion ICU.

Mechanical Circulatory Support: Primer for Consultant Specialists.

Mechanical life support therapies exist in many forms to temporarily replace the function of vital organs. Generally speaking, these tools are supportive therapy to allow for organ recovery but, at times, require transition to long-term mechanical support. This review will examine nonrenal extracorporeal life support for cardiac and pulmonary support as well as other mechanical circulatory support options. This is intended as a general primer and overview to assist nephrologist consultants participating in the care of these critically ill patients who often experience acute renal injury as a result of cardiopulmonary shock and from their exposure to mechanical circulatory support.

Cardiac Surgery Outcomes in an Epicenter of the COVID-19 Pandemic.

As New York State quickly became the epicenter of the COVID-19 pandemic, innovative strategies to provide care for the COVID-19 negative patients with urgent or immediately life threatening cardiovascular conditions became imperative. To date, there has not been a focused analysis of patients undergoing cardiothoracic surgery in the United States during the COVID-19 pandemic. Therefore, we seek to summarize the selection, screening, exposure/conversion, and recovery of patients undergoing cardiac surgery during the peak of the COVID-19 pandemic. We retrospectively reviewed a prospectively maintained institutional database for patients undergoing urgent or emergency cardiac surgery from March 16, 2020 to May 15, 2020, encompassing the peak of the COVID-19 pandemic. All patients were operated on in a single institution in New York City. Preoperative demographics, imaging studies, intraoperative findings, and postoperative outcomes were reviewed. Between March 16, 2020 and May 15, 2020, a total of 54 adult patients underwent cardiac surgery. Five patients required reoperative sternotomy and cardiopulmonary bypass was utilized in 81% of cases. Median age was 64.3 (56.0; 75.3) years. Two patients converted to COVID-19 positive during the admission. There was one operative mortality (1.9%) associated with an acute perioperative COVID-19 infection. Median length of hospital stay was 5 days (4.0; 8.0) and 46 patients were discharged to home. There was 100% postoperative follow up and no patient had COVID-19 conversion following discharge. The delivery of cardiac surgical care was safely maintained in the midst of a global pandemic. The outcomes demonstrated herein suggest that with proper infection control, isolation, and patient selection, results similar to those observed in non-COVID series can be replicated.

Perceptions of Gender Disparities Among Women in Cardiothoracic Anesthesiology.

OBJECTIVE: In this study of women in cardiothoracic anesthesiology, the authors aimed to characterize demographics, roles in leadership, and perceived professional challenges. DESIGN: A prospective cross-sectional survey of female cardiothoracic anesthesiologists in the United States. SETTING: An internet-based survey of 43 questions was sent to women in cardiothoracic anesthesiology. The survey included questions on demographics, leadership, and perceptions of professional challenges including career advancement, compensation, promotion, harassment, and intimidation. PARTICIPANTS: A database of women in cardiothoracic anesthesiology was created via personal contacts and snowball sampling. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 153 responses were analyzed, for a response rate of 65.1%. Most respondents were at the Clinical Instructor or Assistant Professor rank. Many women perceived that compensation, promotion, authorship, and career advancement were affected by gender. Furthermore, 67% of respondents identified having children as having a negative impact on career advancement. Many women reported experiencing derogatory comments (55.6%), intimidation (57.8%), microaggression (69.6%), sexual harassment (25.2%), verbal harassment (45.2%), and unwanted physical or sexual advances (24.4%). These behaviors were most often from a surgical attending, anesthesia attending, or patient. CONCLUSION: This survey study of women in cardiothoracic anesthesiology found that many women perceived inequities in financial compensation, authorship opportunities, and promotion; in addition, many felt that their career advancement was impacted negatively by having children. A striking finding was that the majority of women have experienced intimidation, derogatory comments, and microaggressions in the workplace.

Systematic Review - Neuroprotection of ketosis in acute injury of the mammalian central nervous system: A meta-analysis.

To evaluate the neuroprotection exerted by ketosis against acute damage of the mammalian central nervous system (CNS). Search engines were interrogated to identify experimental studies comparing the mitigating effect of ketosis (intervention) versus non-ketosis (control) on acute CNS damage. Primary endpoint was a reduction in mortality. Secondary endpoints were a reduction in neuronal damage and dysfunction, and an 'aggregated advantage' (composite of all primary and secondary endpoints). Hedges' g was the effect measure. Subgroup analyses evaluated the modulatory effect of age, insult type, and injury site. Meta-regression evaluated timing, type, and magnitude of intervention as predictors of neuroprotection. The selected publications were 49 experimental murine studies (period 1979-2020). The intervention reduced mortality (g 2.45, SE 0.48, p < .01), neuronal damage (g 1.96, SE 0.23, p < .01) and dysfunction (g 0.99, SE 0.10, p < .01). Reduction of mortality was particularly pronounced in the adult subgroup (g 2.71, SE 0.57, p < .01). The aggregated advantage of ketosis was stronger in the pediatric (g 3.98, SE 0.71, p < .01), brain (g 1.96, SE 0.18, p < .01), and ischemic insult (g 2.20, SE 0.23, p < .01) subgroups. Only the magnitude of intervention was a predictor of neuroprotection (g 0.07, SE 0.03, p 0.01 per every mmol/L increase in ketone levels). Ketosis exerts a potent neuroprotection against acute damage to the mammalian CNS in terms of reduction of mortality, of neuronal damage and dysfunction. Hematic levels of ketones are directly proportional to the effect size of neuroprotection.

Valve-sparing root replacement in patients with bicuspid aortopathy: An analysis of cusp repair strategy and valve durability.

OBJECTIVE: Valve-sparing root replacement using reimplantation techniques is increasingly applied to bicuspid aortopathy. Long-term durability of cusp repair is unclear. We analyze midterm results using a conservative approach to cusp repair. METHODS: From 2006 to 2018, 327 patients underwent valve-sparing reimplantation, 66 with bicuspid valves. Leaflets were analyzed after reimplantation. A majority (51/66) required no cusp repair. Fifteen patients had cusp repair limited to closure of unfused raphe or central plication. Patients were followed by echocardiography. RESULTS: Mean age of patients was 44.7 ± 12.3 years. The cusp repair group had a higher incidence of preoperative moderate (10% vs 40%) or severe (4% vs 33.3%) aortic insufficiency (P < .001). There was no operative mortality or major complication. Mean follow-up was 51.6 ± 40.8 months. On postoperative echocardiography, incidence of none, trace, or mild aortic insufficiency was 41.3% (19/46), 43.5% (20/46), and 15.2% (7/46) in the no cusp repair group and 40% (6/15), 40% (6/15), and 20% (3/15) in the cusp repair group, respectively (P = .907). Few patients progressed in degree of aortic insufficiency. No patients required reoperation. At 5 years, freedom from any aortic insufficiency was 46.9% versus 15.8% (P = .013), and freedom from greater than trace aortic insufficiency was 59.1% versus 36.9% (P = .002) due to the higher rate of postoperative trace and mild aortic insufficiency with cusp repair. There was no difference in freedom from greater than mild aortic insufficiency (92.1% vs 100%; P = .33). CONCLUSIONS: Valve-sparing root replacement is reliably performed with bicuspid aortic valves whether or not cusp reconstruction is necessary. Few patients progress to greater than mild aortic insufficiency. Need for reoperation is rare in midterm follow-up.

A Perspective from New York of COVID 19: Effect and impact on cardiac surgery.

BACKGROUND AND AIM: First reported in December of 2019, the COVID-19 pandemic caused by SARS-CoV-2 has had a profound impact on the implementation of care. Here, we describe our institutional experience with a rapid influx of patients at the epicenter of the pandemic. METHODS: We retrospectively review our experience with the departments of cardiology, cardiothoracic surgery, anesthesia, and critical care medicine and summarize protocols developed in the midst of the pandemic. RESULTS: The rapid influx of patients requiring an intensive level of care required a complete restructuring of units, including the establishment of a new COVID-19 negative unit for the care of patients requiring urgent or emergent non-COVID-19 related care including open-heart surgery. This unique unit allowed for the delivery of safe and effective care in the epicenter of the pandemic. CONCLUSIONS: Here, we demonstrate the response of a large tertiary academic medical center to the COVID-19 pandemic. Specifically, we demonstrate how rapid structural changes can allow for the continued delivery of cardiac surgical care with similar outcomes as those reported before the pandemic.

Sex Differences in Outcomes After Coronary Artery Bypass Grafting.

OBJECTIVE: To examine sex differences in inpatient mortality and 30-day and 90-day readmissions after coronary artery bypass grafting (CABG) among a multistate population. DESIGN: A retrospective analysis of patient hospitalization and discharge records. SETTING: All-payer patients in nonpsychiatric hospitals in New York, Maryland, Florida, Kentucky, and California. PARTICIPANTS: A total of 304,080 patients from the State Inpatient Databases Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality from January 2007 to December 2014 who underwent CABG surgery. INTERVENTIONS: Bivariate analysis and multivariate logistic regression were performed to obtain unadjusted rates and adjusted odds ratios, respectively, for in-hospital mortality and readmissions by sex. MEASUREMENTS AND MAIN RESULTS: Of the patients who underwent CABG, 5,699 patients (1.87%) died, including 2,131 women (2.65%) and 3,568 men (1.60%). The authors found that women were 32% more likely to die compared with men (adjusted odds ratio [aOR]: 1.32, 95% confidence interval [CI]: 1.25-1.40) after adjusting for age, race, insurance status, median income, Elixhauser comorbidity index measures, year of procedure, state, and hospital surgical volume. Women, compared with men, also had significantly increased adjusted odds of 30-day and 90-day readmissions (30-day aOR: 1.24, 95% CI: 1.21-1.28; 90-day aOR: 1.25, 95% CI: 1.22-1.28). CONCLUSION: This study demonstrated that female patients who undergo CABG are at a greater risk of in-hospital death and 30-day and 90-day readmission compared with men. This sex-based disparity in outcomes has persisted since identification some 40 years ago.

Hospital Preparedness for COVID-19: A Practical Guide from a Critical Care Perspective.

In response to the estimated potential impact of coronavirus disease (COVID-19) on New York City hospitals, our institution prepared for an influx of critically ill patients. Multiple areas of surge planning progressed, simultaneously focused on infection control, clinical operational challenges, ICU surge capacity, staffing, ethics, and maintenance of staff wellness. The protocols developed focused on clinical decisions regarding intubation, the use of high-flow oxygen, engagement with infectious disease consultants, and cardiac arrest. Mechanisms to increase bed capacity and increase efficiency in ICUs by outsourcing procedures were implemented. Novel uses of technology to minimize staff exposure to COVID-19 as well as to facilitate family engagement and end-of-life discussions were encouraged. Education and communication remained key in our attempts to standardize care, stay apprised on emerging data, and review seminal literature on respiratory failure. Challenges were encountered and overcome through interdisciplinary collaboration and iterative surge planning as ICU admissions rose. Support was provided for both clinical and nonclinical staff affected by the profound impact COVID-19 had on our city. We describe in granular detail the procedures and processes that were developed during a 1-month period while surge planning was ongoing and the need for ICU capacity rose exponentially. The approaches described here provide a potential roadmap for centers that must rapidly adapt to the tremendous challenge posed by this and potential future pandemics.

Noteworthy Literature From 2019 for Cardiothoracic Critical Care.

This annual article summarizes key findings from notable studies published in 2019 relevant to the practice of cardiothoracic critical care medicine. This year's article encompasses updates to the literature on enhanced recovery after cardiac surgery, extracorporeal membranous oxygenation, delirium, and primary graft dysfunction after heart transplant.

Clinical Management of Venoarterial Extracorporeal Membrane Oxygenation.

Venoarterial extracorporeal membrane oxygenation (ECMO) is a well-established technique to rescue patients experiencing cardiogenic shock. As a form of temporary mechanical circulatory support, venoarterial ECMO can be life-saving, but it is resource intensive and associated with substantial morbidity and mortality. Optimal clinical outcomes require specific expertise in the principles and nuances of ECMO physiology and management. Key considerations discussed in this review include hemodynamic assessment and goals; pharmacologic anticoagulation; ECMO weaning strategies; and the prevention, evaluation, and treatment of common complications.

Survey of Workplace Perceptions of Female Anesthesiologists.

BACKGROUND: Disparities encountered by men and women physicians are well documented. However, evidence is lacking concerning the effects of gender on daily practice in the specialty of anesthesiology. AIMS: To evaluate gender disparities perceived by female anesthesiologists. SETTING AND DESIGN: Anonymous, voluntary 30-question, electronic secure REDcap survey. MATERIALS AND METHODS: Survey link was sent via email, Twitter and the Facebook page, Physician Mom's Group. Instructions dictated that only female attending anesthesiologists participate and to partake in the survey one time. STATISTICAL ANALYSIS: Categorical variables were summarized using frequencies and percentages. Associations between categorical variables were tested using Chi-square test. Likert scale items were treated as continuous variables. T-tests were utilized to examine differences between those who reported burnout and those who did not. RESULTS: 502 survey responses were received and analyzed. Female leadership was valued by 78%, yet only 47% had leadership roles. Being female was identified by 51% as negatively affecting career advancement and 90% perceived that women in medicine need to work harder than men to achieve the same career goals. Sexual harassment was experienced by 55%. Nearly 35% of institutions did not offer paid maternity leave. Burnout was identified in 43% of respondents and was significantly associated with work-life balance not being ideal (P < 0.0001), gender negatively affecting career advancement (P < 0.0001), experiencing sexual harassment at work (P = 0.002), feeling the need to work harder than men (P = 0.0033), being responsible for majority of household duties (P = 0.0074), lack of weekly exercise (P = 0.0135) and lack of lactation needs at work (P = 0.0007). CONCLUSIONS: Understanding perceptions of female anesthesiologists may lead to actionable plans aimed at improving workplace equity or conditions.

Robotic Cardiac Surgery Part I: Anesthetic Considerations in Totally Endoscopic Robotic Cardiac Surgery (TERCS).

The application and evolution of total endoscopic robotic cardiac surgery (TERCS) has become greater as institutions and surgeons become more comfortable with robotic technology. Over the years many improvements have been made to facilitate technically challenging cardiac procedures using robotics and increase overall survival and quality of life for these patients. However, a dedicated multidisciplinary approach led by a core group of clinicians is necessary for good patient experience and outcomes. In addition, good communication and performance improvement measures with attention to detailed perioperative management are essential to a successful robotic cardiac program.

Characteristics and anatomic distribution of early vs late stroke after cardiac surgery.

BACKGROUND: The primary objective of this study was to identify the specific predictors of early and late stroke in patients after open heart surgery. Secondary outcomes included (a) risk factors for perioperative stroke, (b) anatomic location of stroke according to time of presentation, and (c) the impact of stroke on operative mortality. METHODS: Adult patients undergoing open cardiac surgery with cardiopulmonary bypass from 2006 to 2016 at the New York Presbyterian Hospital/Weill Cornell Medicine were retrospectively reviewed. In total 7957 patients were included. We compared the demographic and perioperative variables in three groups: no stroke, early stroke, and late stroke using regression analysis. RESULTS: The incidence of perioperative stroke for the entire study period was 1.5% (117 of 7957). Early stroke occurred in 84 (71.8%) patients, whereas late stroke occurred in 33 (28.2%). Early strokes were usually embolic events (64 of 66, 97.0%, P = .66) on the right side (30 of 66, 45.5%, P < .001), in the anterior circulation (38 of 66, 57.6%, P = .001), or in multiple distributions (28 of 66, 42.4%, P = .002). Late strokes were more likely left-sided (16 of 28, 57.1%, P < .001) and uncommonly in both the anterior and posterior hemispheres (1 of 28, 3.6%, P = .001). Stroke, regardless of timing, was a significant predictor of operative mortality (odds ratio, 11.0, confidence interval, 6.1-19.7, P < .001). CONCLUSIONS: Early and late strokes after cardiac surgery have distinct incidence, location, and likely etiology. Both early and late strokes portend a very high incidence of operative mortality.

Should Long-Term Life-Sustaining Care Be Started in Emergency Settings?

Decision making on behalf of an incapacitated patient is challenging, particularly in the context of venoarterial extracorporeal membrane oxygenation (VA-ECMO), a medically complex, high-risk, and costly intervention that provides cardiopulmonary support. In the absence of a surrogate and an advance directive, the clinical team must make decisions for such patients. Because states vary in terms of which decisions clinicians can make, particularly at the end of life, the legal landscape is complicated. This commentary on a case of withdrawal of VA-ECMO in an unrepresented patient discusses Extracorporeal Life Support Organization guidelines for decision making, emphasizing the importance of proportionality in a benefits-to-burdens analysis.