Re-Dosing del Nido cardioplegia in adult cardiac surgery: Perfusion characteristics and outcomes--Is there an optimal redosing strategy?

OBJECTIVES: del Nido cardioplegia is utilized for myocardial protection in adult patients undergoing cardiac surgery; however, no standardized re-dosing protocol exists. We describe perfusion characteristics and clinical outcomes in adult cardiac surgery patients who were re-dosed with del Nido cardioplegia. METHODS: Chart review was performed for adult patients undergoing cardiac surgery (specific inclusion/exclusion criteria below) who received exactly two doses of del Nido cardioplegia from 2012 to 2019; n = 542 patients. The main outcome was a composite endpoint comprised of operative mortality, myocardial infarction, post-operative cardiac support device (CSD), and postoperative decrease in ejection fraction (EF), which was analyzed via multivariable logistic regression (MVLR). A secondary analysis evaluated postoperative vasoactive-inotropic scores (VIS) via gamma log link regression (GLLR) as a more physiologic indication of myocardial recovery. RESULTS: MVLR demonstrated that increased total cardiopulmonary bypass (CPB) time was associated with a positive composite outcome (p < .001), whereas time between doses (p = .237) and the volume of each dose was not (p = .626). GLLR also demonstrated that prolonged CBP, decreased EF, congestive heart failure at time of surgery, and low hematocrit at the start of the surgery were all associated with higher VIS. CONCLUSIONS: In this retrospective study, variations in re-dosing strategy for del Nido cardioplegia do not affect postoperative outcomes and increased CPB time is associated with increased operative mortality, myocardial infarction, need for post-operative CSDs, and reduced postoperative EF, and increased VIS, irrespective of the re-dosing strategy. Further studies are warranted to to identify additional patient and operative characteristics that predispose to complications.

Central aortic versus axillary artery cannulation for aortic arch surgery.

Objective: Central aortic cannulation for aortic arch surgery has become more popular over the last decade; however, evidence comparing it with axillary artery cannulation remains equivocal. This study compares outcomes of patients who underwent axillary artery and central aortic cannulation for cardiopulmonary bypass during arch surgery. Methods: A retrospective review of 764 patients who underwent aortic arch surgery at our institution between 2005 and 2020 was performed. The primary outcome was failure to achieve uneventful recovery, defined as having experienced at least 1 of the following: in-hospital mortality, stroke, transient ischemic attack, bleeding requiring reoperation, prolonged ventilation, renal failure, mediastinitis, surgical site infection, and pacemaker or implantable cardiac defibrillator implantation. Propensity score matching was used to account for baseline differences across groups. A subgroup analysis of patients undergoing surgery for aneurysmal disease was performed. Results: Before matching, the aorta group had more urgent or emergency operations (P = .039), fewer root replacements (P < .001), and more aortic valve replacements (P < .001). After successful matching, there was no difference between the axillary and aorta groups in failure to achieve uneventful recovery, 33% versus 35% (P = .766), in-hospital mortality, 5.3% versus 5.3% (P = 1), or stroke, 8.3% versus 5.3% (P = .264). There were more surgical site infections in the axillary group, 4.8% versus 0.4% (P = .008). Similar results were seen in the aneurysm cohort with no differences in postoperative outcomes between groups. Conclusions: Aortic cannulation has a safety profile similar to that of axillary arterial cannulation in aortic arch surgery.

Effect of venoarterial extracorporeal membrane oxygenation initiation timing on tricuspid valve surgery outcomes.

Objectives: Tricuspid valve surgery is associated with high rates of shock and in-hospital mortality. Early initiation of venoarterial extracorporeal membrane oxygenation after surgery may provide right ventricular support and improve survival. We evaluated mortality in patients undergoing tricuspid valve surgery based on the timing of venoarterial extracorporeal membrane oxygenation. Methods: All consecutive adult patients undergoing isolated or combined surgical tricuspid valve repair or replacement from 2010 to 2022 requiring venoarterial extracorporeal membrane oxygenation use were stratified by initiation in the operating room (Early) versus outside of the operating room (Late). Variables associated with in-hospital mortality were explored using logistic regression. Results: There were 47 patients who required venoarterial extracorporeal membrane oxygenation: 31 Early and 16 Late. Mean age was 55.6 years (standard deviation, 16.8), 25 (54.3%) were in New York Heart Association class III/IV, 30 (60.8%) had left-sided valve disease, and 11 (23.4%) had undergone prior cardiac surgery. Median left ventricular ejection fraction was 60.0% (interquartile range, 45-65), right ventricular size was moderately to severely increased in 26 patients (60.5%), and right ventricular function was moderately to severely reduced in 24 patients (51.1%). Concomitant left-sided valve surgery was performed in 25 patients (53.2%). There were no differences in baseline characteristics or invasive measurements immediately before surgery between the Early and Late groups. Venoarterial extracorporeal membrane oxygenation was initiated 194 (23.0-840.0) minutes after cardiopulmonary bypass in the Late venoarterial extracorporeal membrane oxygenation group. In-hospital mortality was 35.5% (n = 11) in the Early group versus 68.8% (n = 11) in the Late group (P = .037). Late venoarterial extracorporeal membrane oxygenation was associated with in-hospital mortality (odds ratio, 4.00; 1.10-14.50; P = .035). Conclusions: Early postoperative initiation of venoarterial extracorporeal membrane oxygenation after tricuspid valve surgery in high-risk patients may be associated with improvement in postoperative hemodynamics and in-hospital mortality.

Trends in Comprehensive Thoracic Case Experience Among General Surgery Residents in the Modern Integrated Cardiothoracic Residency Era: Review of Twenty Years of Resident Case Logs.

BACKGROUND: Thoracic surgery training among general surgery residents in the United States is regulated by the Accreditation Council for Graduate Medical Education (ACGME) to ensure exposure to subspecialty fields during residency. Thoracic surgery training has changed over time with the placement of work hour restrictions, the emphasis on minimally invasive surgery, and increased subspecialization of training like integrated six-year cardiothoracic surgery programs. We aim to investigate how these changes over the past twenty years have affected thoracic surgery training among general surgery residents. METHODS: ACGME general surgery resident case logs from 1999 to 2019 were reviewed. Data included exposure to the thorax via thoracic, cardiac, vascular, pediatric, trauma, and alimentary tract procedures. Cases from the above categories were consolidated to determine the comprehensive experience. Descriptive statistics were performed over four 5-year Eras (Era 1:1999-2004, Era 2: 2004-2009, Era 3: 2009-2014, Era 4: 2014-2019). RESULTS: Between Era 1 and Era 4, there was an increase in thoracic surgery experience (37.6 ± 1.03 vs 39.3 ± .64; P = .006). The mean total thoracic experience for thoracoscopic, open, and cardiac procedures was 12.89 ± 3.76, 20.09 ± 2.33, and 4.98 ± 1.28, respectively. There was a difference between Era 1 and Era 4 in thoracoscopic (8.78 ± .961 vs 17.18 ± .75; P < .001) and open thoracic experience (22 ± .97 vs 17.06 ± .88; P < .001), and a decrease in thoracic trauma procedures (3.7 ± .06 vs 3.2 ± .32; P = .03). DISCUSSION: Over twenty years there has been a similar, to slight increase in thoracic surgery exposure among general surgery residents. The changes seen in thoracic surgery training reflect the overall movement of surgery towards minimally invasive surgery.

Society for Cardiovascular Angiography and Interventions Shock Classification to Stratify Outcomes of Extracorporeal Membrane Oxygenation.

We applied the Society for Cardiovascular Angiography and Interventions (SCAI) schema to cardiogenic shock (CS) patients treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) to assess performance in this high acuity group of patients. Records of adult patients receiving VA-ECMO for CS at our institution from 01/2015 to 12/2019 were reviewed. Post-cardiotomy and noncardiogenic shock patients were excluded. A total of 245 patients were included, with a median age of 59 years [IQR: 48-67]; 159 (65%) were male. There were 34 (14%) patients in Stage C, 82 (33%) in D, and 129 (53%) in E. Of E patients, 88 (68%) were undergoing cardiopulmonary resuscitation. Median ECMO duration decreased with stage (C:7, D:6, E:4 days, P < 0.001). In-hospital mortality increased (C:35%, D:56%, E:71%, P < 0.001) and myocardial recovery decreased with stage (C:65%, D:35%, E:30%, P < 0.001). Acute kidney injury (C:35%, D:45%, E:54%, P = 0.045), acute liver failure (C:32%, D:66%, E:76%, P < 0.001), and infection (C:35%, D:28%, E:16%, P = 0.004) varied among groups. Multivariable analysis revealed age (HR=1.02), male sex (HR=0.62), and E classification (HR=2.69) as independently associated with 1-year mortality. Competing-risks regression identified D (SHR=0.53) and E classification (SHR=0.45) as inversely associated with myocardial recovery. In patients treated with VA-ECMO for CS, the SCAI classification provided robust risk stratification.

National outcomes of bridge to multiorgan cardiac transplantation using mechanical circulatory support.

BACKGROUND: Little is known regarding the profile of patients with multiorgan failure listed for simultaneous cardiac transplantation and secondary organ. In addition, few studies have reported how these patients are bridged with mechanical circulatory support (MCS). In this study, we examined national data of patients listed for multiorgan transplantation and their outcomes after bridging with or without MCS. METHODS: United Network for Organ Sharing data were reviewed for adult multiorgan transplantations from 1986 to 2019. Post-transplant patients and total waitlist listings were examined and stratified according to MCS status. Survival was assessed via Cox regression in the post-transplant cohort and Fine-Gray competing risk regression with transplantation as a competing risk in the waitlist cohort. RESULTS: There were 4534 waitlist patients for multiorgan transplant during the study period, of whom 2117 received multiorgan transplants. There was no significant difference in post-transplant survival between the MCS types and those without MCS in the whole cohort and heart-kidney subgroup. Fine-Gray competing risk regression showed that patients bridged with extracorporeal membrane oxygenation had significantly greater waitlist mortality compared with those without MCS when controlling for preoperative characteristics (subdistribution hazard ratio, 2.27; 95% confidence interval, 1.48-3.47; P < .001), whereas those bridged with a ventricular assist device had a decreased incidence of death compared with those without MCS (subdistribution hazard ratio, 0.78; 95% confidence interval, 0.63-0.96; P = .017). CONCLUSIONS: MCS, as currently applied, does not appear to compromise the survival of multiorgan heart transplant patients. Waitlist data show that extracorporeal membrane oxygenation patients have profoundly worse survival irrespective of preoperative factors including organ type listed. Survival on the waitlist for multiorgan transplant has improved across device eras.

Ethnic Disparities in Ileal Pouch Anal Anastomosis Outcomes: An ACS-NSQIP Study.

INTRODUCTION: Ileal pouch-anal anastomosis (IPAA) has become the gold standard operation performed for patients with ulcerative colitis (UC) who require colectomy for medically refractory disease or colitis-associated neoplasia. This study aims to evaluate whether differences in surgical outcomes following IPAA creation is associated with minority ethnicity using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical outcomes database. METHODS: The ACS-NSQIP proctectomy-targeted data files (2016-2019) were reviewed to identify patients who underwent an IPAA creation (Current Procedural Terminology codes: 44157, 44158, 44211, and 45113). Demographic, comorbidity, perioperative characteristics, and postoperative outcomes, particularly total-morbidity, surgical site infection, and anastomotic leak, were compared for White, African-American, Hispanic, and Asian patients. Separate multivariable logistic regressions were calculated for each outcome of interest. Certain postoperative outcomes required collation to be analyzed due to low numbers, such as combining all surgical site infections (SSIs), anastomotic leak, and septic complications as "infection complications". For each regression, a P value of <0.05 was considered to be significant. RESULTS: A total of 1462 patients were identified who underwent an IPAA creation. There were 1290 (88.2%) Caucasian, 66 (4.5%) African-American, 49 (3.4%) Hispanic, and 57 (3.9%) Asian patients. Minority race or ethnicity was not associated with higher odds of total morbidity, readmission, reoperation, the development of any SSI, anastomotic leak, or other septic complications as compared to White patients. African-American ethnicity was associated with higher odds of developing postoperative bleeding complications (odds ratio [OR] 2.45, 95% confidence interval [CI] 1.15-5.21; P = 0.020) and postoperative renal dysfunction (OR 4.32, CI 1.43-13.07; P = 0.010) as compared to White patients. Elevated body mass index (BMI) was associated with higher odds of developing an SSI (OR 1.03, CI 1.00-1.06; P = 0.045), or an "infection" complication (OR 1.04, CI 1.01-1.07; P = 0.012), but was protective against bleeding complications (OR 0.94, CI 0.9-0.98; P = 0.004). Smoking was associated with higher odds of developing an SSI, anastomotic leak, or septic complications in the combined "infection" regression analysis (OR 2.02, CI 1.25-3.26; P = 0.004). In the analysis of total-morbidity, both hypertension (OR 1.64, CI 1.11-2.42; P = 0.013) and an ASA Class score >3 (OR 1.36, CI 1.03-1.79; P = 0.029) were associated with increased odds of complications. CONCLUSIONS: This analysis of the ACS-NSQIP national database data suggests that ethnicity is not associated with disparities in surgical outcomes following IPAA surgery. African-American ethnicity was however associated with higher odds of developing postoperative bleeding complications and renal dysfunction as compared to White patients. Elevated BMI and smoking history are associated with an increased risk of SSI, anastomotic leak and septic complications.

Correlation between aortic valve protein levels and vector flow mapping of wall shear stress and oscillatory shear index in patients supported with continuous-flow left ventricular assist devices.

BACKGROUND: Continuous-flow left ventricular assist devices commonly lead to aortic regurgitation, which results in decreased pump efficiency and worsening heart failure. We hypothesized that non-physiological wall shear stress and oscillatory shear index alter the abundance of structural proteins in aortic valves of left ventricular assist device (LVAD) patients. METHODS: Doppler images of aortic valves of patients undergoing heart transplants were obtained. Eight patients had been supported with LVADs, whereas 10 were not. Aortic valve tissue was collected and protein levels were analyzed using mass spectrometry. Echocardiographic images were analyzed and wall shear stress and oscillatory shear index were calculated. The relationship between normalized levels of individual proteins and in vivo echocardiographic measurements was evaluated. RESULTS: Of the 57 proteins of interest, there was a strong negative correlation between levels of 15 proteins and the wall shear stress (R < -0.500, p ≤ 0.05), and a moderate negative correlation between 16 proteins and wall shear stress (R -0.500 to -0.300, p ≤ 0.05). Gene ontology analysis demonstrated clusters of proteins involved in cellular structure. Proteins negatively correlated with WSS included those with cytoskeletal, actin/myosin, cell-cell junction and extracellular functions. C: In aortic valve tissue, 31 proteins were identified involved in cellular structure and extracellular junctions with a negative correlation between their levels and wall shear stress. These findings suggest an association between the forces acting on the aortic valve (AV) and leaflet protein abundance, and may form a mechanical basis for the increased risk of aortic leaflet degeneration in LVAD patients.

Disparities in the treatment of cardiogenic shock: does sex matter?

OBJECTIVES: The use of extracorporeal life support for cardiogenic shock has significantly increased over the past decade. However, there are insufficient data for the presence of sex-associated outcomes differences. Our study assesses differences between male and female patients placed on venoarterial extracorporeal life support (VA-ECLS) for cardiogenic shock from an international database. METHODS: This is a multicentre, retrospective study on 9888 adult patients on VA-ECLS for cardiogenic shock from the Extracorporeal Life Support Organization registry from 2011 to 2019. The 1:1 nearest neighbour propensity score matching was performed. The primary end point was in-hospital mortality. Secondary end points include bleeding, infection and other complications. RESULTS: There were 6747 (68%) male patients and 3141 (32%) female patients. Male patients were more likely to have history of myocardial infarction, coronary artery disease, diabetes, chronic kidney disease and congestive heart failure. Female patients were more likely to be centrally cannulated. After propensity score matching, there was no difference seen in in-hospital mortality. In regards to complications, female patients were more likely to experience limb ischaemia, whereas males were more likely to receive renal replacement therapy and have longer hospital stays. Multivariable logistic regression confirmed sex was not independently associated with mortality. CONCLUSIONS: There was no difference in-hospital mortality between male and female patients receiving VA-ECLS for cardiogenic shock. Female patients were more likely to have limb ischaemia as a complication. Varying cannulation approaches for female patients should be further investigated.

Assessing sex-based differences in postsurgical clinical outcomes after use of del Nido cardioplegia.

OBJECTIVES: del Nido cardioplegia is used to pharmacologically arrest the heart during cardiac surgery and decrease reperfusion- and ischaemia-related myocardial injury. Studies have demonstrated the physiological differences between male and female hearts, potentially related to cardiac size or myocyte calcium handling; we aimed to assess for between-sex differences in clinical outcomes after receipt of del Nido cardioplegia. METHODS: Patients who underwent coronary artery bypass or coronary artery bypass graft/valve surgery at our institution using del Nido cardioplegia (January 2014 to December 2019) were included (n = 2118). Clinical data were collected retrospectively. After the creation of a propensity-matched cohort (n = 1252), multivariable logistic regression was used to analyse binary postoperative outcomes, and a Gamma model was used for a continuous postoperative outcome. Our primary end-point was a composite end-point comprised of 30-day mortality and/or need for a post-bypass mechanical support device. RESULTS: The final cohort included 459 females and 793 males (matched up to 1:2, all standardized mean differences <0.1). Multivariable logistic regression showed that biological sex was not associated with the composite primary end-point (odds ratio = 0.898, P = 0.779). A Gamma model indicated that there were no sex-related differences in vasoactive-inotropic scores reflecting vasopressor and inotrope usage at the time of patient operating room exit (exp[est] = 1.394, P = 0.189). CONCLUSIONS: Our findings showed no significant between-sex differences in clinical outcomes after receiving del Nido cardioplegia, suggesting adequate myocardial protection as currently administered. Further research is warranted to elicit if there are sex-based differences between cardioplegic solutions. IRB APPROVAL DATE (PROTOCOL NUMBER): 26 May 2021 (AAAR8359).

In COVID-19 Patients Who Suffer In-Hospital Cardiac Arrest, Cardiopulmonary Resuscitation Outcomes May Be Impacted by Arrest Etiology and Local Pandemic Conditions.

OBJECTIVES: The utility and risks to providers of performing cardiopulmonary resuscitation after in-hospital cardiac arrest in COVID-19 patients have been questioned. Additionally, there are discrepancies in reported COVID-19 in-hospital cardiac arrest survival rates. We describe outcomes after cardiopulmonary resuscitation for in-hospital cardiac arrest in two COVID-19 patient cohorts. DESIGN: Retrospective cohort study. SETTING: New York-Presbyterian Hospital/Columbia University Irving Medical Center in New York, NY. PATIENTS: Those admitted with COVID-19 between March 1, 2020, and May 31, 2020, as well as between March 1, 2021, and May 31, 2021, who received resuscitation after in-hospital cardiac arrest. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Among 103 patients with coronavirus disease 2019 who were resuscitated after in-hospital cardiac arrest in spring 2020, most self-identified as Hispanic/Latino or African American, 35 (34.0%) had return of spontaneous circulation for at least 20 minutes, and 15 (14.6%) survived to 30 days post-arrest. Compared with nonsurvivors, 30-day survivors experienced in-hospital cardiac arrest later (day 22 vs day 7; p = 0.008) and were more likely to have had an acute respiratory event preceding in-hospital cardiac arrest (93.3% vs 27.3%; p < 0.001). Among 30-day survivors, 11 (73.3%) survived to hospital discharge, at which point 8 (72.7%) had Cerebral Performance Category scores of 1 or 2. Among 26 COVID-19 patients resuscitated after in-hospital cardiac arrest in spring 2021, 15 (57.7%) had return of spontaneous circulation for at least 20 minutes, 3 (11.5%) survived to 30 days post in-hospital cardiac arrest, and 2 (7.7%) survived to hospital discharge, both with Cerebral Performance Category scores of 2 or less. Those who survived to 30 days post in-hospital cardiac arrest were younger (46.3 vs 67.8; p = 0.03), but otherwise there were no significant differences between groups. CONCLUSIONS: Patients with COVID-19 who received cardiopulmonary resuscitation after in-hospital cardiac arrest had low survival rates. Our findings additionally show return of spontaneous circulation rates in these patients may be impacted by hospital strain and that patients with in-hospital cardiac arrest preceded by acute respiratory events might be more likely to survive to 30 days, suggesting Advanced Cardiac Life Support efforts may be more successful in this subpopulation.

A Randomized Controlled Trial Examining the Impact of an Anorectal Surgery Multimodal Enhanced Recovery Program on Opioid Use.

BACKGROUND: Anorectal cases may be a common gateway to the opioid epidemic. Opioid reduction is inherent in enhanced recovery after surgery (ERAS) protocols, but little work has evaluated ERAS in these cases. OBJECTIVE: To determine if ERAS could reduce postoperative opioid utilization in ambulatory anorectal surgery without sacrificing patient pain or satisfaction. METHODS: A randomized controlled trial assigned ambulatory anorectal patients to ERAS (experimental) or routine care (surgeon's choice) for pain management (control) over 30-days postoperatively. Primary outcome was overall days of opioid use. Secondary outcomes included pain and satisfaction scores over multiple time points and new persistent opioid use. The Visual Analog Scale, Functional Pain Scale, and EQ-5D-3L measured patient-reported pain and satisfaction. Univariate analysis compared outcomes overall and at individual time points. Two-way mixed ANOVA evaluated pain and satisfaction measures between groups and over time. RESULTS: Thirty-two patients were randomized into each arm (64 total). The control group consumed significantly more opioids after discharge (median 121.3MME vs 23.5MME, P < 0.001). Significantly more control patients requested additional narcotics (P  =  0.004), made unplanned calls (P = 0.009), and had unplanned clinic visits (P = 0.003). The control group had significantly more days on opioids (mean 14.4 vs 2.2, P < 0.001). Three control patients (9.4%) versus no experimental patients had new persistent opioid use. The mean global health, EQ5D-3L, Visual Analog Scale, and Functional Pain scores were comparable between groups over time. CONCLUSIONS: An ERAS protocol in ambulatory anorectal surgery is feasible, and resulted in reduced opioid use, and healthcare utilization, with no difference in pain or patient satisfaction. This challenges the paradigm that extended opioids are needed for effective postoperative pain management.

Sex differences in patients with cardiogenic shock requiring extracorporeal membrane oxygenation.

OBJECTIVE: Our study assesses differences between male and female patients placed on venoarterial extracorporeal membrane oxygenation for cardiogenic shock. METHOD: We retrospectively analyzed 574 adult patients placed on venoarterial extracorporeal membrane oxygenation for cardiogenic shock at our institution between January 2007 and December 2018. Baseline characteristics and outcomes were assessed. Propensity score matching was used to compare outcomes. The primary end point was in-hospital mortality. Secondary outcomes include limb ischemia, limb ischemia interventions, distal perfusion cannula placement, stroke, bleeding, and continuous venovenous hemofiltration initiation. RESULTS: There were 394 male patients (69%) and 180 female patients (31%). After adjusting for baseline differences, propensity score matching compared 171 male patients with 171 female patients. No difference was seen between men and women in in-hospital mortality (60.2% vs 56.7%; P = .59), limb ischemia (47.4% vs 45.6%; P = .83), limb ischemia surgery (15.2% vs 12.9%; P = .64), bleeding (49.7% vs 49.1%; P = 1), continuous venovenous hemofiltration initiation (39.2% vs 32.7%; P = .26), and stroke (8.2% vs 9.4%; P = .85). Multivariable logistic regression showed that female patients who died were more likely to have had chronic kidney disease (odds ratio [OR], 2.67; 95% confidence interval [CI], 1.09-6.53; P = .032) than surviving women. Male patients who died were more likely to have had coronary artery disease (OR, 2.25; 95% CI, 1.34-3.78; P = .002) and higher lactate levels (OR, 1.14; 95% CI, 1.08-1.21; P < .001) than surviving men. Women with cardiac transplant primary graft dysfunction were more likely to survive (OR, 0.04; 95% CI, 0.01-0.27; P = .001), whereas men with cardiac transplant primary graft dysfunction were less likely to survive (OR, 0.28; 95% CI, 0.11-0.71; P = .007), than patients with other shock etiologies. CONCLUSIONS: After adjusting for baseline difference, there was no difference in outcomes between male and female patients despite differing risk profiles for in-hospital mortality.

Re-dosing of del Nido cardioplegia in adult cardiac surgery requiring prolonged aortic cross-clamp.

OBJECTIVES: Few data exist on the use of del Nido cardioplegia in adults, specifically during operations requiring prolonged aortic cross-clamp. In this pilot study, we evaluate outcomes of patients undergoing surgery with cross-clamp time >3 h based on re-dosing strategy, using either full dose (FD; 1:4 blood to crystalloid ratio) or dilute (4:1 blood to crystalloid ratio) solution. METHODS: Consecutive adult patients (>18 years) undergoing cardiac surgery from 2012 to 2018 with cross-clamp time >3 h were reviewed. Patients were excluded if del Nido cardioplegia was not used. Patients were categorized into FD or dilute groups based on re-dosing solution. Propensity score matching was used to control for baseline differences between groups. The primary endpoint was in-hospital mortality. Other outcomes examined included: postoperative mechanical support, arrhythmia, stroke, dialysis and cardiac function. RESULTS: Included for analysis were 173 patients (115 male) with median age of 63.8 (interquartile range 53.9-73.1). Major comorbidities included diabetes (45), cerebrovascular disease (34), hypertension (131), atrial fibrillation (52) and previous cardiac surgery (83). There were 108 patients (62%) who received FD re-dosing, while 65 (38%) received dilute. A greater proportion of patients in the dilute group received retrograde delivery, for both induction (32/108 vs 39/65, P < 0.001) and re-dose (50/108 vs 53/65, P < 0.001). After propensity score matching, in-hospital mortality was not different between groups (6/48 vs 1/48, P = 0.131). There were no differences in rates of postoperative mechanical circulatory support, stroke, left ventricular ejection fraction or right ventricle dysfunction. CONCLUSIONS: Del Nido cardioplegia has been used in complex cardiac surgery requiring prolonged cross-clamp. Re-dosing can be performed with either FD or dilute del Nido solution with no statistical difference in outcomes.

Suprasternal Versus Transfemoral Access for Transcatheter Aortic Valve Replacement: Insights From a Propensity Score Matched Analysis.

Background Suprasternal access is an alternative access strategy for transcatheter aortic valve replacement (TAVR) where the innominate artery is cannulated from an incision above the sternal notch. To date, suprasternal access has never been compared with transfemoral TAVR. Thus, we sought to assess safety, feasibility, and early clinical outcomes between suprasternal and transfemoral access for patients undergoing TAVR. Methods and Results We evaluated patients from 2 institutional prospective, observational registries containing 1348 patients. Patients were selected in a 2:1 ratio (transfemoral:suprasternal) on the basis of propensity score matching. The primary outcome was in-hospital mortality, and secondary outcomes included the incidence of ischemic stroke, major bleeding, vascular injury, left bundle-branch block, and permanent pacemaker implantation at 30-day follow-up. Propensity score matching identified 89 patients undergoing suprasternal TAVR and 159 patients undergoing transfemoral TAVR suitable for analysis. There was no significant difference between suprasternal TAVR and transfemoral TAVR with respect to in-hospital mortality (1.1% versus 0.6%; odds ratio [OR], 1.80; 95% CI, 0.11-29.06; P=0.680). No patients in either cohort suffered an ischemic stroke. The incidence of major bleeding (2.2% versus 2.5%; OR, 0.89; 95% CI, 0.16-4.96; P=0.895) and vascular injury (1.1% versus 1.9%; OR, 0.59; 95% CI, 0.06-5.77; P=0.651) did not differ significantly. The frequency of left bundle-branch block (9.4% versus 15.8%; OR, 0.56; 95% CI, 0.24-1.30; P=0.177) and permanent pacemaker implantation (11.2% versus 5.9%; OR, 2.01; 95% CI, 0.75-5.45; P=0.169) were not statistically significantly different. Conclusions Suprasternal TAVR was safe and achieved promising short-term clinical outcomes when compared with transfemoral TAVR. Future studies seeking to identify the optimal alternative access site should evaluate suprasternal TAVR access alongside other substitutes for transfemoral TAVR.

Obesity is independently associated with septic shock, renal complications, and mortality in a multiracial patient cohort hospitalized with COVID-19.

BACKGROUND: Obesity has emerged as a risk factor for severe coronavirus disease 2019 (COVID-19) infection. To inform treatment considerations the relationship between obesity and COVID-19 complications and the influence of race, ethnicity, and socioeconomic factors deserves continued attention. OBJECTIVE: To determine if obesity is an independent risk factor for severe COVID-19 complications and mortality and examine the relationship between BMI, race, ethnicity, distressed community index and COVID-19 complications and mortality. METHODS: A retrospective cohort study of 1,019 SARS-CoV-2 positive adult admitted to an academic medical center (n = 928) and its affiliated community hospital (n-91) in New York City from March 1 to April 18, 2020. RESULTS: Median age was 64 years (IQR 52-75), 58.7% were men, 23.0% were Black, and 52.8% were Hispanic. The prevalence of overweight and obesity was 75.2%; median BMI was 28.5 kg/m2 (25.1-33.0). Over the study period 23.7% patients died, 27.3% required invasive mechanical ventilation, 22.7% developed septic shock, and 9.1% required renal replacement therapy (RRT). In the multivariable logistic regression model, BMI was associated with complications including intubation (Odds Ratio [OR]1.03, 95% Confidence Interval [CI]1.01-1.05), septic shock (OR 1.04, CI 1.01-1.06), and RRT (OR1.07, CI 1.04-1.10), and mortality (OR 1.04, CI 1.01-1.06). The odds of death were highest among those with BMI ≥ 40 kg/m2 (OR 2.05, CI 1.04-4.04). Mortality did not differ by race, ethnicity, or socioeconomic distress score, though Black and Asian patients were more likely to require RRT. CONCLUSIONS AND RELEVANCE: Severe complications of COVID-19 and death are more likely in patients with obesity, independent of age and comorbidities. While race, ethnicity, and socioeconomic status did not impact COVID-19 related mortality, Black and Asian patients were more likely to require RRT. The presence of obesity, and in some instances race, should inform resource allocation and risk stratification in patients hospitalized with COVID-19.

Ethical Framework to Guide Decisions of Treatment Over Objection.

BACKGROUND: Whether to proceed with a medical intervention over the objection of a patient who lacks capacity is a common problem facing practitioners. Despite this, there is a notable gap in the literature describing how to proceed in such situations in an ethically rigorous and consistent fashion. We elaborate on the practical application of the 2018 Rubin and Prager 7-question algorithm for ethics consultations about treatment over objection and we describe the impact of each of the 7 questions. STUDY DESIGN: We retrospectively review a series of consultations at Columbia University Irving Medical Center between April 2017 and May 2020 for treatment over objection in adult patients determined to lack capacity. Outcomes about the final ethics recommendation and the assessment of each of the 7 questions are reported. The statistical analysis was designed to determine which of the 7 questions in the algorithm were most predictive of the final ethics recommendation. RESULTS: In our series, there was an ethics recommendation to proceed over the objection of a patient in 63% of consultations. Although all 7 questions were considered to be important to the ethical analysis of a patient's situation, the presence of logistical barriers to treatment and the imminence of harm to a patient without treatment emerged as the most significant drivers of the recommendation of whether to proceed over objection or not. CONCLUSIONS: Cases of treatment over objection in a patient lacking capacity are frequently encountered problems that require a careful balance of patient autonomy and a physician's duty of beneficence. The application of the Rubin and Prager 7-question algorithm reliably guides a care team through such a complex ethical dilemma.

Daytime variation does not impact outcome of cardiac surgery: Results from a diverse, multi-institutional cardiac surgery network.

OBJECTIVE: Recent single-center and experimental data suggested greater adverse cardiac events for patients undergoing aortic valve replacement (AVR) in the morning (AM) versus the afternoon (PM). However, previous studies in patients undergoing coronary artery bypass grafting (CABG) have found no similar time-related difference. We examined the impact of AM versus PM operative time on surgical outcomes of CABG and AVR in a diverse, multi-institutional cardiac surgery network between January 2008 and September 2018. METHODS: The AM group included patients whose surgery start time was between 6:30 and 9 AM, whereas noon to 2:30 PM was considered PM (8901 AM/1962 PM) for CABG and (2598 AM/617 PM) for AVR. Because of imbalances in sample size, risk factors, and Society of Thoracic Surgeons predicted risk between groups, propensity score matching using all baseline characteristics was used to create 2 well-matched patient groups whose outcomes were compared. RESULTS: After propensity score matching, there was no difference in mortality, stroke, prolonged ventilation, renal failure, deep sternal wound infection, reoperation, myocardial injury, atrial fibrillation, or readmission between AM and PM groups for both isolated CABG and AVR. However, there were mixed differences noted in intensive care unit length of stay, postoperative length of stay, blood product use, and crossclamp time. Findings were stable when accounting for site and physician effects, whereas subgroup analyses showed similar findings in the elective, diabetic, Hispanic, and off-pump patient populations. CONCLUSIONS: There were no differences in operative mortality nor in major morbidity between well-matched AM and PM patients undergoing either CABG or AVR.

Adoption and Usage of Video Telehealth in a Large, Academic Department of Surgery.

Objectives: To understand the impact that video telehealth has on outpatient visit volume and reimbursement as a method of maintaining care. Background: As the coronavirus disease 2019 (COVID-19) spread across the United States starting in 2020, it caused numerous areas of medicine and healthcare to reexamine how we provide care to patients across all disciplines. One method clinicians used to rapidly adapt to these transformed settings was video telehealth, which was previously rarely used. Methods: This retrospective review examined outpatient volume and reimbursement data of a large, academic department of surgery. The study reviewed data during 2 time periods: pre-COVID-19 (February 1, 2020, to March 15, 2020) and COVID-19 (March 16, 2020, to April 30, 2020). Results: During the period of February 1 to April 30, 13,193 outpatient visits were analyzed. The pre-COVID-19 group contained 9041 (68.5%) visits, whereas the COVID-19 group contained 4152 (31.4%) visits. All divisions noted a drop in visit volume from pre-COVID-19 compared with COVID-19. There was rapid adoption of video telehealth during COVID-19, which made up most patient visits during that time (61.3%). We also found that video telehealth led to significant reimbursements while also allowing patients in numerous states to receive care. Conclusions: Previously, video telehealth was used by clinicians in a small portion of outpatient visits. However, safety concerns surrounding COVID-19 forced multiple changes to the way care is provided. Although outpatient volume at our center was less than that before the pandemic, video telehealth was rapidly adopted by providers and allowed for safe and effective outpatient care to patients in a high number of states while still being reimbursed at a high rate.