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.

Optimum heparin dose in off-pump coronary artery bypass grafting: A systematic review and meta-analysis.

INTRODUCTION: Off-pump coronary artery bypass grafting (OPCABG) was introduced many years ago aiming to reduce the known complications of conventional on-pump coronary surgeries. Heparin is required during the procedures, but the available protocols have diverse dosage regimens. The primary objective of this systematic review is to examine the effect of different heparin doses on the outcomes of OPCABG. EVIDENCE ACQUISITION: MEDLINE and EMBASE were searched. Four reviewers identified eligible clinical trials. Two reviewers extracted data and independently assessed the risk of bias using Cochrane tool. The primary outcome was the activated clotting time (ACT) at three minutes. The secondary outcomes were proportion of patients requiring blood products and the length of hospital stay. An aggregate data approach was used. EVIDENCE SYNTHESIS: Three single-center randomized studies recruiting 256 patients were included. The studies compared low-dose (1.5-2 mg/kg) and high-dose (3 mg/kg) heparin boluses. The overall mean difference for ACT after three minutes between low- and high-dose heparin is - 126.16 (95% CI: - 142.19, - 110.14). The proportion of patients requiring blood products after surgery [odd ratio 1.27 (95% CI: 0.69, 2.32)] or the overall length of stay [mean difference -0.15 (95% CI: -0.84, 0.53)] did not differ between the heparin doses. CONCLUSIONS: In OPCABG, high-dose compared with low-dose heparin did not affect the utilization of more blood products or increased the overall length of stay. Unsurprisingly, ACT values were higher in the high-dose heparin group. Larger and adequately powered randomized clinical trials are indicated to resolve the uncertainty.

Retrograde Percutaneous Tracheostomy. Early Experience With a Cadaveric Case Report.

Despite the many accomplishments since the introduction of percutaneous dilational (PDT) tracheostomy, we continue to observe emerging complications as we forge ahead in intensive care practice. As a result of this, we provide a new technique that could avoid some complications, notably posterior tracheal wall injury, bronchoscopic or endotracheal tube puncture, and false track. The new technology was evaluated on a 75-year-old Caucasian male cadaver was selected for a novel PDT technique. A wire with a sharp terminal end passed through the bronchoscopic channel and punctured the trachea from inside towards the skin. The wire was pulled and directed towards the mediastinum. The rest of the technique was carried out like a routine procedure. The procedure was technically feasible; further clinical trials are required to confirm the validity of this technique.

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.

Insight into appropriate medication prescribing for elderly in the COVID-19 era.

Coronavirus disease 2019 (COVID-19) complicates clinical management in elderly population. There is an additional need to properly treat and monitor elderly COVID-19 patients. This paper discusses the inappropriate medication prescribing in the elderly and suggests an updated valid assessment tool considering COVID-19 and its treatment.

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.

Robotic Coronary Revascularization is Feasible and Safe: 10-year Single-Center Experience.

Objective: The purpose of this study is to investigate the outcomes of patients undergoing robotic surgical coronary revascularization whether total endoscopic coronary artery bypass (TECAB) or robotic-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) in our center. Methods: This is a retrospective single-center study. It was conducted in the heart hospital at Hamad Medical Corporation, Qatar. We retrospectively studied all cases that had single grafts, left internal mammary artery (LIMA) to left anterior descending (LAD) coronary artery through a minimally invasive approach, either TECAB grafting or RA-MIDCAB grafting operations between February 2009 and December 2020. Both procedures were performed with the assistance of the da Vinci robotic system. In TECAB, the robotic system was used to harvest LIMA and perform the anastomosis with LAD. Whereas in RA-MIDCAB, LIMA was harvested by the robotic system but the anastomosis of LIMA to LAD was performed under direct vision through a small anterior thoracotomy incision. Seventy-one patients' files from the medical records department were reviewed. Preoperative data included age, gender, ethnicity, body mass index (BMI), cardiac risk factors, Euro score, presentation, and the results of the cardiac investigations. The intraoperative data were the type of procedure, operative time, and whether the procedure was completed as planned or converted to thoracotomy or sternotomy. The postoperative data included the length of hospital stay, postoperative complications, 3-month clinic follow-up, and the need for repeat coronary angiography or revascularization. Results: We found that our patients' ages ranged from 31 to 70 years. The majority were males, with 64 (90.14%) patients. Thirty-one (44.93%) patients were found to have a BMI of 25-29.9 Kg/m2. Forty-seven (66.2%) patients were hypertensive and 37 (52.11%) were diabetic. Dyslipidemia was reported in 35 (50%) patients. TECAB was the primary procedure in 47 (66.2%) patients and the rest underwent RA-MIDCAB. Only 7 (10.14%) patients underwent a planned hybrid procedure. The procedure was completed as planned in 52 (73.2%) patients. The mean operative time was 355.9 ± 95.79 min. Fourteen (19.72%) TECAB procedures were converted to MIDCAB, whereas 5 (7.04%) required sternotomy. Thirteen (18.3%) patients were extubated on the table, 47 (66%) patients were extubated in <24 h, and 7 (9.8%) patients were extubated after 24 h of the procedure. Forty-two (59%) patients stayed only 24 h in ICU and 24 (33.8%) spent more than 24 h. Blood transfusion was required in 8 (11.2%) patients. Only 2 (2.8%) patients experienced bleeding after the surgery. Postoperative infection was observed in 3 (4.29%) patients. No new cerebrovascular accident was detected among the patients after the procedure. Median postoperative hospital stay was 5 days, interquartile range 2, range (2-39). During the 3-month postoperative follow-up, we found that three unplanned coronary angiographies were required for repeat intervention, one of them for LIMA-LAD anastomosis. No redo surgery was performed. Thirty-day mortality was reported in two patients only. Conclusion: From our experience over more than 10 years in robotic cardiac surgery in Qatar, we believe that robotic coronary revascularization is safe and feasible in selected patients mainly with single vessel coronary artery disease but should be performed in specialized centers and by robotic-trained surgeons.

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.

Association of ruptured sinus of Valsalva aneurysm and congenital ventricular septal defect: a case series.

BACKGROUND: Ruptured sinus of Valsalva aneurysm (RSOVA) is rare, and it is more common in Asians. Typically, the patient presents with acute/subacute shortness of breath (SOB) and chest pain. Echocardiography is the gold standard for diagnosis in most of these cases. Surgery has remained the first line of management. CASE SUMMARY: We present two cases of RSOVA in which the patients presented to the emergency department with SOB. Their preoperative echocardiography results showed RSOVA into the right ventricle. During surgical repair, ventricular septal defect (VSD) was also found. DISCUSSION: RSOVA is frequently associated with other congenital anomalies, and most often with VSD. In our cases, we believe that VSDs were missed preoperatively because either the large aneurysmal sacs covered the VSD or there was overlap between the two shunts. Additionally, in the first case, right ventricular pressure was high approaching systemic pressure, which probably reduced the shunt across the VSD. Early intervention is recommended to prevent endocarditis or enlargement of the ruptured aneurysm; long-term results were excellent after surgical repair. Most patients undergo surgery between 20 and 40 years of age, and the reported survival rate is 95% at 20 years. If left untreated, patients typically die of heart failure or endocarditis within 1 year after onset of symptoms.

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.

Postoperative Cardiac Surgery Outcomes in a Statin-Native Population.

BACKGROUND: Statin utilization had been associated with improved survival after cardiac surgery. We aim to study whether perioperative treatment with statin could be associated with increased postoperative complications. DESIGN: This was a retrospective, descriptive, single-center study. SETTINGS: We analyzed morbidity after cardiac surgery as well as the outcome related to statin therapy in a tertiary cardiac center. PATIENTS: A total of 202 consecutive patients were enrolled over 1 year after cardiac surgery. INTERVENTION: Patients were divided into two groups; Group I - statin users and Group II - nonusers. MEASUREMENTS: Measurements were baseline and follow-up laboratory markers for muscular injury including cardiac muscle and hepatic injuries and renal injuries. RESULTS: The incidence of rhabdomyolysis and elevation of liver enzymes did not differ between both groups. Postoperative atrial fibrillation was significantly lower in the statin group (P = 0.02). In addition, peak cardiac troponin and creatine kinase-MB did not differ significantly in the statin group. Statin-treated group had significant lower length of mechanical ventilation, and length of stay in the Intensive Care Unit and hospital (P = 0.036, 0.04, and 0.027, respectively). CONCLUSIONS: Therapy with statin before cardiac surgeries was not associated with high incidence of adverse events.

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.

Acute kidney injury induces high-sensitivity troponin measurement changes after cardiac surgery.

BACKGROUND: The value of cardiac troponin as a risk assessment tool for cardiac disease in the setting of end-stage renal diseases (ESRD) is not equivalent to its value in those with normal renal function. This consideration had not been studied in settings of acute kidney injury (AKI). We aim to explore the diagnostic value of high sensitive troponin T (hsTnT) in the settings of cardiac surgery-induced AKI. METHODS: Single center observational retrospective study. Based on the AKI Network, patients divided into 2 groups, group I without AKI (259 patients) and group II with AKI (100 patients) where serial testing of hsTnT and creatine kinase (CK)-MB were followed in both groups. Patients with (ESRD) were excluded. RESULTS: The mean age in our study was 55.1 ± 10.2 years. High association of AKI (27.8%) was found in our patients. Both groups were matched regarding the age, gender, body mass index, the association of diabetes or hypertension, and Euro score. AKI group had significantly higher mortality 5% vs group I 1.1% (p = 0.03). The hsTnt showed a significant sustained rise in the AKI group as compared to the non-AKI group, however CK-MB changes were significant initially but not sustained. The AKI group was more associated with heart failure 17.9% vs 4.9% (p = 0.001); and post-operative atrial fibrillation, 12.4% vs 2.9% (p = 0.005). Lengths of ventilation, stays in ICU and in hospital were significantly higher in the AKI group. CONCLUSIONS: Unlike the CK-MB profile, the hsTnT showed significant changes between both groups all over the course denoting possible delayed clearance in patients with AKI.