Association between hospital-acquired functional decline and 2-year readmission or mortality after cardiac surgery in older patients: a multicenter, prospective cohort study.

BACKGROUND: Hospital-acquired functional decline (HAFD) is a new predictor of poor prognosis in hospitalized older patients. AIMS: We aimed to assess the impact of HAFD on the prognosis of older cardiac surgical patients 2 years after discharge. METHODS: This multicenter prospective cohort study assessed 293 patients with cardiac disease aged ≥ 65 years who underwent cardiac surgery at 7 Japanese hospitals between June 2017 and June 2018. The primary endpoint was the composite outcome of cardiovascular-related readmission and all-cause mortality 2 years after discharge. HAFD was assessed using the total Short Physical Performance Battery at hospital discharge. RESULTS: The primary outcome was observed in 17.3% of the 254 included patients, and HAFD was significantly associated with the primary outcome. Female sex (hazard ratio [HR], 2.451; 95% confidence interval [CI] 1.232-4.878; P = 0.011), hemoglobin level (HR, 0.839; 95% CI 0.705-0.997; P = 0.046), preoperative frailty (HR, 2.391; 95% CI 1.029-5.556; P = 0.043), and HAFD (HR, 2.589; 95% CI 1.122-5.976; P = 0.026) were independently associated with the primary outcome. The incidence rate of HAFD was 22%, with female sex (odds ratio [OR], 1.912; 95% CI 1.049-3.485; P = 0.034), chronic obstructive pulmonary disease (OR, 3.958; 95% CI 1.413-11.086; P = 0.009), and the time interval (days) between surgery and the start of ambulation (OR, 1.260, 95% CI 1.057-1.502; P = 0.010) identified as significant factors. DISCUSSION: HAFD was found to be an independent prognostic determinant of the primary outcome 2 years after discharge. CONCLUSION: HAFD prevention should be prioritized in the hospital care of older cardiac surgery patients.

Hospital-Acquired Functional Decline and Clinical Outcomes in Older Cardiac Surgical Patients: A Multicenter Prospective Cohort Study.

This study aimed to determine the effect of hospital-acquired functional decline (HAFD) on prognosis, 1-year post-hospital discharge, of older patients who had undergone cardiac surgery in seven Japanese hospitals between June 2017 and June 2018. This multicenter prospective cohort study involved 247 patients with cardiac disease aged ≥65 years. HAFD was defined as a decrease in the short physical performance battery at hospital discharge compared with before surgery. Primary outcomes included a composite outcome of frailty severity, total mortality, and cardiovascular readmission 1-year post-hospital discharge. Secondary outcomes were changes in the total score and sub-item scores in the Ki-hon Checklist (KCL), assessed pre- and 1-year postoperatively. Poor prognostic outcomes were observed in 33% of patients, and multivariate analysis identified HAFD (odds ratio [OR] 3.43, 95% confidence interval [CI] 1.75-6.72, p < 0.001) and low preoperative gait speed (OR 2.47, 95% CI 1.18-5.17, p = 0.016) as independent predictors of poor prognosis. Patients with HAFD had significantly worse total KCL scores and subscale scores for instrumental activities of daily living, mobility, oral function, and depression at 1-year post-hospital discharge. HAFD is a powerful predictor of prognosis in older patients who have undergone cardiac surgery.

Perioperative changes in physical performance affect short-term outcome in elderly cardiac surgery patients.

AIM: The effect of changes in physical performance during the perioperative period on the prognosis of older patients undergoing cardiac surgery has not been studied in detail. This study aimed to investigate the effect of perioperative changes in physical performance on the prognosis of older patients undergoing cardiac surgery. METHODS: A total of 223 patients were graded as either frail or non-frail according to a cutoff score of 9 based on preoperative Short Physical Performance Battery scores. The non-frail patients were further grouped into high, recovery, or decreased score groups, depending on their score at the time of discharge compared with preoperative scores. Basic characteristics, preoperative and postoperative clinical data, 6-month post-discharge mortality, readmission rates, and vital function (Kihon Checklist scores) were compared. RESULTS: In total, 16.1% of patients were in the frail group, while 18.4%, 35.4%, and 30.1% were in the decreased, recovery, and high score groups, respectively. The Short Physical Performance Battery scores in the decreased group were significantly lower at discharge, and the rate of readmission was significantly higher (17.7%, P < 0.05). In addition, the Kihon Checklist scores were significantly lower than the preoperative scores (5.7 ± 4.0 vs 8.6 ± 5.5, P < 0.05). CONCLUSIONS: Both preoperative and postoperative physical performance must be considered when predicting the prognosis of older patients undergoing cardiac surgery. Geriatr Gerontol Int 2021; 21: 676-682.

Indocyanine Green Fluorescence Image-guided Laparoscopic Hepatectomy Enabled Resection of a Tumor Invisible With Ultrasonography.

BACKGROUND: Ultrasonography (US) is widely used for pre-operative detection of liver tumors. However, US does not have high resolution and very small tumors, tumors located near the liver surface, or those in cirrhotic livers are often not detected. CASE REPORT: A 47-year-old woman with a previous surgery for sigmoid colon cancer (T3N1bM0 Stage3b) showed a liver tumor on the surface of segment 2 by contrast-enhanced computed tomography (CT) and gadoliniumethoxybenzyldiethlenetriaminepen-taacetic acid (Gd-EOB-DTPA) magnetic resonance imaging (MRI). However, preoperative US could not identify a tumor lesion at the same site. The most likely preoperative diagnosis was metastasis from her sigmoid colon cancer and laparoscopic liver resection was performed. Intraoperative ultrasonography (IOUS) did not identify the tumor, but it was visualized with indocyanine green (ICG) fluorescence at the surface of segment 2. Laparoscopic liver resection was performed under fluorescence guidance. Pathological examination showed a pseudotumor with negative margins. CONCLUSION: ICG fluorescence imaging can allow visualization of liver tumors that are undetectable on US.

Impact of a Rehabilitation Protocol and a Dedicated Therapist in the Intensive Care Unit on Physical Function and Activities of Daily Living.

OBJECTIVES: The goal of this study was to determine the effects of an intensive care unit (ICU) rehabilitation protocol with dedicated therapists on the physical function and activities of daily living (ADL) of patients on discharge from the ICU. METHODS: This retrospective study included patients who started rehabilitation during their ICU stay. Patients were divided into three groups: the Usual Care group (before the introduction of the rehabilitation protocol), the Protocol group (after the introduction of the rehabilitation protocol), and the PT + Protocol group (with a dedicated therapist in addition to the rehabilitation protocol). The standard interventions in the Protocol group and the PT + Protocol group were set according to the protocol based on the level of consciousness and strength of each individual patient. Patients' age, APACHE II score, length of ICU stay, length of hospital stay, and the Functional Status Score for the ICU (FSS-ICU) and Medical Research Council score (MRC score) on discharge from the ICU were compared among the three groups. RESULTS: There were no significant differences among the three groups in age and APACHE II score. The MRC and FSS-ICU scores were significantly higher in the PT + Protocol and Protocol groups than in the Usual Care group. Furthermore, the lengths of ICU stay and hospital stay were lower in the PT + Protocol group than in the Usual Care group. CONCLUSIONS: Introduction of the rehabilitation protocol improved the limb strength and ADL of patients. Moreover, the presence of dedicated therapists in addition to the protocol reduced the lengths of ICU and hospital stays.

Effect of obesity and underweight status on the hospital-acquired functional decline in patients with cardiovascular surgery: an analysis of data from a prospective observational multicenter cohort study.

OBJECTS: The aim of this study was to determine the association between underweight or obese status and hospital- acquired functional decline (HAFD) following cardiovascular surgery. METHODS: We performed a retrospective, observational, multicenter cohort study of cardiovascular surgery patients between April, 2010, and June, 2017. Body mass index (BMI) was categorized into four classes: underweight group (< 18.5 kg/m2), normal weight group (18.5 to < 25 kg/m2), overweight group (25 to < 30 kg/m2), and obese group (≥ 30 kg/m2). HAFD was defined as a decrease of at least one point on the short physical performance battery score at discharge, compared with the preoperative score. RESULTS: A total of 3,850 adult patients were included in the analysis data set (median age 72 years, 35% female). A total of 811 (21.0%) patients demonstrated HAFD: 27.2% in the underweight group, 21.3% in the normal weight group, 18.8% in the overweight group, and 19.3% in the obese group. The relative risk for HAFD was 1.381 (95% CI 1.052-1.814) for the underweight group versus the normal weight group, although that is comparable to the obese group after adjustment by confounding factors. Analyses of subgroup interactions showed that the relative risk of HAFD in the obese group compared with the normal group was higher in patients with muscle wasting (p < 0.05). CONCLUSION: HAFD was significantly worse for underweight patients following cardiovascular surgery. In contrast, obese status was not associated with HAFD, exclusive of the obese patients with muscle wasting.

Postoperative atrial fibrillation is associated with delayed early rehabilitation after heart valve surgery: a multicenter study.

OBJECTIVE: Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery. The aim of this multicenter study was to determine the relationship between POAF and patients' progress in early rehabilitation after heart valve surgery. METHODS: We enrolled 302 patients (mean age, 69±10 years) who had undergone heart valve surgery. POAF was monitored using continuous electrocardiogram telemetry, and the Short Physical Performance Battery (SPPB) was used to assess lower-extremity function before surgery and at the time of discharge. Progress in early rehabilitation was evaluated by the duration from the surgery to independent walking. We determined factors associated delayed early rehabilitation and evaluated the interplay of POAF and delayed early rehabilitation in increasing the risk of decline in lower-extremity function from preoperatively to hospital discharge. RESULTS: Multivariate analysis determined POAF to be independent predictors of delayed early rehabilitation after heart valve surgery (OR: 3.906, P = .01). The association between delayed early rehabilitation and decline in lower extremity function was stronger in patients with POAF (OR: 2.73, P = .041) than in those without (OR: 2.22, P = .052). CONCLUSIONS: POAF was clinical predictors of delayed early rehabilitation in patients undergoing heart valve surgery. The combination of POAF with delayed early rehabilitation conferred a high risk of decline in lower-extremity function during hospitalization.

Impact of preoperative frailty on regaining walking ability in patients after cardiac surgery: Multicenter cohort study in Japan.

BACKGROUND: This study aimed to examine the relationship between preoperative frailty and the reacquisition of walking ability in patients after cardiac surgery. METHODS: 450 patients who underwent cardiac surgery were included as subjects. We implemented the Short Physical Performance Battery (SPPB) before surgery and classified subjects into three groups according to the SPPB score: SPPB 10-12, SPPB 7-9, and SPPB 0-6. We examined the postoperative day and the rate of the reacquisition of walking ability after surgery, and compared them among three groups. In addition, we calculated the cutoff value for the SPPB score to regain walking ability by performing a receiver operating characteristic curve analysis. RESULTS: The postoperative day of the reacquisition of walking ability in SPPB 10-12 was earlier than other groups (SPPB 10-12: 4.0 days, SPPB 7-9: 4.5 days, SPPB 0-6: 6.0 days, p < 0.01), and SPPB 0-6 was lower than other groups in the rate of the reacquisition of walking ability (SPPB 10-12: 98.8%, SPPB 7-9: 96.4%, SPPB 0-6: 76.2%, p < 0.01). The cutoff value for SPPB was ≧9(Area under the curve: 0.85, sensitivity: 0.82, specificity: 0.71, p < 0.001). CONCLUSION: Preoperative frailty affected the day of the reacquisition of walking ability in patients after cardiac surgery. The preoperative SPPB cutoff value which indicates the feasibility of reacquisition walking ability after surgery was ≧ 9.

Clinical characteristics of functional recovery after coronary artery bypass graft surgery in Japanese octogenarians.

[Purpose] This study aimed to elucidate characteristics of postoperative physical functional recovery in octogenarians undergoing coronary artery bypass graft surgery. [Subjects and Methods] This was a multi-center, retrospective study. Nine hundred and twenty-seven elective isolated coronary artery bypass graft surgeries were evaluated (746 males and 181 females, mean age: 68.6 years, range: 31-86 years). Participants were stratified according to age < 80 years (n = 840; mean age, 67.1; range, 31-79) or > 80 years (n = 87; mean age, 82.2; range, 80-86). Patient characteristics and postoperative physical functional recovery outcomes were compared between groups. [Results] There was no significant difference between groups when considering the postoperative day at which patients could sit on the edge of the bed, stand at bedside, or walk around the bed. The postoperative day at which patients could walk 100 m independently was later in octogenarians, when compared with non-octogenarians (6.1 ± 3.2 days vs. 4.9 ± 3.9 days). In octogenarians, the percentage of patients who could walk 100 m independently within 8 days after surgery was 79.5%. [Conclusion] A postoperative target time in octogenarians for independent walking, following coronary artery bypass grafting, can be set at approximately 6 days.

[Determinants of prolonged mechanical ventilation after cardiac surgery].

PURPOSE: This study aimed to examine factors that delay weaning from ventilation after cardiac surgery. METHODS: A retrospective examination was made on 1,033 patients who had undergone cardiac surgery through a midsternal incision between January 2009 and July 2011. The items examined were duration of postoperative ventilation, patient's background, and other surgical information. If patients were weaned within 24 hours from intensive care unit (ICU) admission, they were included in the timely weaning group. If patients required 24 hours or more to be weaned, they were included in the delayed weaning group. RESULTS: There was a relationship between prolonged ventilation and the following factors: emergency surgery, history of arrhythmia, history of motor system disorder, preoperative estimated glomerular filtration rate (eGFR), preoperative New York Heart Association (NYHA) classification, preoperative left ventricular ejection fraction (LVEF), operative method, operative time, blood loss, intraoperative fluid management, and number of days from surgery until achievement of independent gait. The independent factors delaying extubation were emergency surgery, preoperative NYHA classification, preoperative LVEF, operative method, operative time, blood loss, and intraoperative fluid management(p<0.05). CONCLUSION: Surgical invasiveness and preoperative heart failure were involved in the prolonged ventilation after cardiac surgery.

Cigarette Smoking does not Induce Plasma or Pulmonary Oxidative Stress after Moderate-intensity Exercise.

[Purpose] Cigarette smoking increases oxidative stress, which is a risk factor for several diseases. Moreover, strenuous exercise has been shown to induce plasma and pulmonary oxidative stress in young cigarette smokers. However, no previous reports have demonstrated whether plasma and pulmonary oxidative stress occur after moderate-intensity exercise. Therefore, the aim of this study was to clarify whether moderate-intensity exercise induces pulmonary and plasma oxidative stress in smokers. [Subjects] Ten young male smokers and 10 young male nonsmokers participated in this study. [Methods] Plasma hydroperoxide concentrations were measured at baseline and then immediately and 15 min after moderate-intensity exercise. Hydrogen peroxide concentrations in exhaled breath condensate were measured at baseline and after exercise. [Results] No significant interactions were found between smokers and nonsmokers in terms of hydroperoxide or hydrogen peroxide concentrations following moderate-intensity exercise at any time point. [Conclusion] These findings suggested that moderate-intensity exercise did not induce plasma or pulmonary oxidative stress in young cigarette smokers.

Plasma oxidative stress is induced by single-sprint anaerobic exercise in young cigarette smokers.

Cigarette smoking increases oxidative stress, which is a risk factor for several diseases. Smoking has also been reported to enhance plasma oxidative stress during strenuous exercise. However, no prior study has examined the changes in plasma oxidative stress after single-sprint anaerobic exercise in cigarette smokers. The purpose of this study was to investigate these changes in young cigarette smokers by measuring reactive oxygen species generation and total antioxidant content. Participants were 15 male smokers (mean age: 25·9 ± 2·9 years) and 18 male non-smokers (mean age: 24·2 ± 4·3 years). Hydroperoxide concentration and biological antioxidant potential (BAP) in plasma were measured at baseline and after the Wingate anaerobic test. A significant interaction between group and time was observed for plasma hydroperoxide concentration (P = 0·037). Plasma hydroperoxide concentration was significantly increased after exercise in both smokers and non-smokers (P = 0·001 and <0·001, respectively). However, no significant interaction was observed between groups by time on plasma BAP (P = 0·574), and a main effect of time was observed (P<0·001). Plasma BAP was significantly increased after exercise in both groups (both, P<0·001). These findings indicate that plasma oxidative stress is higher in cigarette smokers than in non-smokers after single-sprint anaerobic exercise, which may increase the risk of oxidative damage.

Factors determining achievement of early postoperative cardiac rehabilitation goal in patients with or without preoperative kidney dysfunction undergoing isolated cardiac surgery.

BACKGROUND: The aim of this multicenter study was to evaluate the relationship between preoperative kidney function, postoperative acute kidney injury (AKI), and postoperative fluid balance (POFB) with the progress of early postoperative cardiac rehabilitation (CR) in patients undergoing isolated cardiac surgery. METHODS: Four hundred twenty three consecutive patients (137 females, 286 males, aged 66±13 years) who underwent various elective cardiac surgeries in the participating institutes were selected and divided into 5 groups depending on chronic kidney disease (CKD) stage. We evaluated the effects of CKD stage on the progress of early postoperative CR, and analyzed the factors determining the achievement of Japanese Circulation Society (JCS) early postoperative CR guidelines goal. RESULTS: Initiation of sitting (F=7.59, p<0.01) and standing (F=4.83, p<0.01), walking (F=4.40, p<0.01), and 100-m unassisted walk (F=13.09, p<0.01) were related with severity of preoperative CKD stage. The proportion of patients who could not achieve JCS early postoperative CR guideline goal was 15.0% in patients with CKD and 12.9% in patients without CKD. Multivariable analyses identified Risk, Injury, Failure, Loss, and End-stage Kidney (RIFLE) classification (of postoperative AKI) and blood urea nitrogen as factors determining achievement of early postoperative CR goal in patients with CKD; and POFB/preoperative body weight (PBW), RIFLE classification as determinants in patients without CKD. Using the receiver-operating characteristics curve analysis to predict achievement of the early postoperative CR goal, POFB/PBW 4.9% was identified as the cut-off value for achievement of the JCS early postoperative CR guideline goal. CONCLUSION: Preoperative CKD stage correlated significantly with the progress of early postoperative CR after cardiac surgery. Independent determinants of achieving JCS early postoperative CR guideline goal were postoperative AKI in patients with or without CKD, and POFB/PBW only in patients without CKD.