A Fatal Case of Rhizopus azygosporus Pneumonia Following COVID-19.

We report a fatal case of Rhizopus azygosporus pneumonia in a 56-year-old man hospitalized for COVID-19 who had received methylprednisolone and tocilizumab. Although COVID-associated pulmonary aspergillosis has been widely documented, mucormycosis has been rarely reported. In this patient, receipt of two commonly used immunosuppressants likely contributed to mucormycosis risk, suggesting the need for vigilance in hospitalized patients with COVID-19.

Off-pump coronary artery bypass in octogenarians: results of a statewide, matched comparison.

OBJECTIVES: Off-pump coronary artery bypass grafting (OPCAB) may have advantages in the elderly. Although proven safe, it remains unclear whether OPCAB provides a short-term survival benefit in octogenarians. We sought to compare outcomes using propensity matching between OPCAB and conventional surgery in a statewide database. METHODS: We identified all octogenarians (≥ 80 years) who underwent isolated coronary artery bypass grafting (CAB) at 10 different centers in the state of Maryland from July 2011 to June 2016. We separated patients into two groups: OPCAB and on-pump coronary artery bypass (ONCAB). Patients were assigned propensity scores with a semi-parsimonious logistic regression model and matched 1:1 by the nearest-neighbor principle. A revascularization ratio was determined between the number of distal grafts sewn and number of diseased coronaries (≥ 50% stenosis). RESULTS: In total, 926 octogenarians underwent isolated CAB (8.2% of all CAB): 798 (86%) had ONCAB and 128 (14%) had OPCAB. Propensity matching yielded 128 well-matched pairs. Operative mortality was similar between groups (OPCAB 5.5% vs ONCAB 3.1%, p = 0.364). Rates of complications were similar between groups. OPCAB patients had a lower revascularization ratio (0.92 vs 1.15, p < 0.001), but more frequent use of left internal mammary artery (97 vs 89%, p = 0.017), and decreased intraoperative transfusion rates (33 vs 63%, p < 0.001). CONCLUSIONS: In comparing outcomes among octogenarians across the state of Maryland, OPCAB and ONCAB had similar mortality and morbidity. However, OPCAB was associated with a lower revascularization ratio. Thus, our results demonstrate no short-term survival benefit of OPCAB over ONCAB in octogenarians.

Bilateral Internal Mammary Artery Use in Diabetic Patients: Friend or Foe?

BACKGROUND: Bilateral internal mammary artery (BIMA) grafting in diabetic patients undergoing coronary artery bypass grafting remains controversial. Our study compared morbidity and mortality between (1) diabetic and nondiabetic BIMA patients and (2) diabetic BIMA versus diabetic patients who underwent left internal mammary artery (LIMA) grafting only. METHODS: Patients who underwent isolated coronary artery bypass grafting from July 2011 to June 2016 at any of the 10 Maryland Cardiac Surgery Quality Initiative centers were propensity scored across 16 variables. Diabetic BIMA patients were matched 1:1 by nearest neighbor matching to nondiabetic BIMA patients and were separately matched 1:1 to diabetic LIMA patients. We calculated observed-to-expected (O/E) ratios for composite morbidity/mortality, operative mortality, unplanned reoperation, stroke, renal failure, prolonged ventilation, and deep sternal wound infection and compared ratios among matched populations. RESULTS: During the study period, 812 coronary artery bypass grafting patients received BIMA grafts, including 302 patients (37%) with diabetes. We matched 259 diabetic and nondiabetic BIMA patients. O/E ratios were higher in matched diabetic (versus nondiabetic) BIMA patients when comparing composite morbidity/mortality, reoperation, stroke, renal failure, and prolonged ventilation (all O/E ratios >1.0); however, the O/E ratio for operative mortality was higher in nondiabetic BIMA patients. We additionally matched 292 diabetic BIMA to diabetic LIMA patients. Diabetic BIMA patients had a higher O/E ratio for composite morbidity/mortality, operative mortality, stroke, renal failure, and prolonged ventilation. CONCLUSIONS: In this statewide analysis, diabetic patients who received BIMA grafts (compared with diabetic patients with LIMA grafts or nondiabetic patients with BIMA grafts) had higher O/E ratios for composite morbidity/mortality as a result of higher O/E ratios for major complications.

Less Is More: Results of a Statewide Analysis of the Impact of Blood Transfusion on Coronary Artery Bypass Grafting Outcomes.

BACKGROUND: Debate persists over the association between blood transfusions, especially those considered discretionary, and outcomes after cardiac operations. Using data from the Maryland Cardiac Surgery Quality Initiative, we sought to determine whether outcomes differed among coronary artery bypass grafting (CABG) patients receiving 1 U of red blood cells (RBCs) vs none. METHODS: We used a statewide database to review patients who underwent isolated CABG from July 1, 2011, to June 30, 2016, across 10 Maryland cardiac surgery centers. We included patients who received 1 U or fewer of RBCs from the time of the operation through discharge. Propensity scoring, using 20 variables to control for treatment effect, was performed among patients who did and did not receive a transfusion. These two groups were matched 1:1 to assess for differences in our primary outcomes: operative death, prolonged postoperative length of stay (>14 days), and a composite postoperative respiratory complication of pneumonia or reintubation, or both. RESULTS: Of 10,877 patients who underwent CABG, 6,124 (56%) received no RBCs (group 1) during their operative hospitalization, and 981 (9.0%) received 1 U of RBCs (group 2), including 345 of 981 patients (35%) who received a transfusion intraoperatively. Propensity score matching generated 937 well-matched pairs. Compared with group 2, propensity-matched analysis revealed significantly greater 30-day survival in group 1 (99% vs 98%, p = 0.02) and reduced incidence of prolonged length of stay (3.7% vs 4.0%, p < 0.01). CONCLUSIONS: Our collaborative statewide analysis demonstrated that even 1 unit of blood was associated with significantly worse survival and longer length of stay after CABG. Multiinstitutional quality initiatives may seek to address discretionary transfusions and possess the potential to improve patient outcomes.

Fast track minimally invasive transmyocardial revascularization.

OBJECTIVE: : We evaluated the initial results of a fast-track discharge protocol for patients undergoing minimally invasive transmyocardial revascularization (MiTMR). METHODS: : Fifteen male patients, aged 64.5 ± 9.2 years, with an ejection fraction of 46.8% ± 9.9%, underwent MiTMR through a mini-left anterior thoracotomy aided by robotic-controlled thoracoscopic assistance. A postoperative management protocol included immediate extubation, early chest tube and pulmonary artery catheter removal, and mobilization within 12 hours. RESULTS: : There were no operative arrhythmias or in-hospital mortalities. Three of 15 patients developed left lower lobe atelectasis, delaying discharge between 2 and 5 days. Overall hospital length of stay was 1.4 ± 1.2 days, although 12 of 15 patients (80%) were discharged to home in 23 hours. Mild-moderate cardiomyopathy (ejection fraction 30%-50%) was not associated with prolonged length of stay. Mean hospital profit margin was $1882.50. One 30-day readmission occurred on day 23 for rapid atrial fibrillation, and one death occurred on day 11. CONCLUSIONS: : Despite these high-risk patients having end-staged, ischemic coronary artery disease, most MiTMR patients can be discharged to home in less than 24 hours. Perioperative morbidity and mortality rates are relatively low, and hospital profit margins are modest.

Transmyocardial laser therapy: a strategic approach.

BACKGROUND: Coronary artery bypass and percutaneous intervention have become the established methods of coronary revascularization in treating angina pectoris. Subsets of angina patients, however, are not amenable to either of these procedures. Transmyocardial laser revascularization (TMR) has been developed as a potential treatment to address such patients, and clinical research to date illustrates the success of TMR for this patient group. STRATEGIC PLAN SUMMARY: Although the symptoms of ischemic heart disease manifest themselves in a variety of ways, the best results with TMR are seen in patients with severe angina rather than in patients with silent ischemia or congestive heart failure. Potential TMR patients receive diagnostic tests to determine if and where the therapy should be applied. A recent cardiac catheterization is required to document the status of and the coronary-system suitability for the planned intervention. It is not appropriate to assume that a patient with nonbypassable, noninterventional coronary artery disease has to be relegated to medical therapy only. Additionally, echocardiography demonstrates the status of cardiac valves and segmental wall motion activity. This knowledge allows the surgeon to determine the sequence of surgery and if abnormalities are present. Once the decision to use TMR use has been made, there are 2 approaches--sole therapy or adjunctive therapy. TMR is not to be substituted for a feasible bypass graft, but the best time to make this decision may well be during the surgery itself, because grafts that appear surgically feasible on an angiogram may be less feasible after the chest has been opened. The decision to perform sole-therapy TMR in the absence of bypassable vessels clearly must be made before opening the chest. Whether to use cardiopulmonary bypass (CPB) and the sequence in which to perform TMR and bypass grafts are based on surgeon preference. The advantage of performing TMR on CPB is that channels can quickly be lased without pause. A potential advantage of performing TMR before bypass grafts is that "channel leak" (bleeding) can be minimized by the conclusion of the surgery. Complete revascularization has become technically more difficult because of the increasing use of percutaneous approaches and because patients are being referred for coronary artery bypass grafting much later in the course of their coronary disease progression than before. TMR may well be a viable alternative to bypassing a heavily diseased, previously intervened, small-diameter coronary artery. Thus, a model in which myocardial perfusion is considered within the context of the natural circulation can be conceived as an alternative to a model in which circulation is altered by interventional, surgical, and/or transmyocardial methods. TMR has been shown to be effective in accomplishing a complete revascularization when the restoration of circulation to ischemic territories with interventional therapy, bypass surgery, or a combination of both has been ineffective. We recommend that interested users follow this "complete revascularization strategy" algorithm for all ischemic vessels being considered for interventional or surgical treatment. Running each diseased vessel through this thought process will ensure that available treatment options are considered in the optimization of a patient's outcome. CONCLUSION: The use of TMR for angina relief has evolved into a clinically proven technology that has enabled physicians to address difficult revascularization cases with a therapy that is safe and effective.

Robotic-assisted off-pump sole transmyocardial revascularization: case report.

Thoracoscopic transmyocardial revascularization (TMR) has been recently demonstrated. We report 2 patients who underwent robotic-assisted thoracoscopic off-pump sole TMR. A 2-inch minimally invasive left anterolateral thoracotomy was made. Pericardial dissection and TMR were performed in an open manner facilitated by improved visualization using voice-activated robotic-assisted thoracoscopy (AESOP, Computer Motion, Santa Barbara, CA, USA). Patient 1 was a 73-year-old man with class IV angina who underwent coronary artery bypass grafting (CABG) x4 20 years earlier. Cardiac catheterization revealed occluded grafts, no native vessels that were amenable to percutaneous coronary intervention (PCI) or CABG, and an ejection fraction (EF) of 55%. Forty-five Holmium-Yag (CardioGenesis, Foothill Ranch, CA, USA) laser channels were created in the left ventricular wall. Total operating room (OR) time was 93 minutes. He was extubated in the OR and was discharged from the intensive care unit (ICU) in 18 hours and from the hospital on the second postoperative day angina free. Patient 2 was a 48-year-old woman with class IV angina who had undergone CABG x6 3 years earlier but who had persistent chest pain following the revascularization. After 12 cardiac readmissions in 1 year, including multiple PCIs, a recent catheterization showed patent grafts except for the circumflex branches and an EF of 45%. Forty-six channels were created in the left ventricle in a similar fashion. OR time was 62 minutes, ICU time was 20 hours, and postoperative length of stay was 2 days. The patient also was angina free at discharge. This report suggests that robotic-assisted thoracoscopy provides enhanced visualization and efficient delivery during off-pump sole TMR, and this technique may be associated with reduced operative times and improved recovery time.

Improved patient outcomes when transmyocardial revascularization is used as adjunctive revascularization.

BACKGROUND: Transmyocardial revascularization (TMR) has been recently used to treat patients with angina for whom angioplasty/stenting and/or coronary artery bypass grafting (CABG) is no longer an option. METHODS: A retrospective review of 255 consecutive patients who required CABG was done. Group 1 patients (n = 219) underwent complete revascularization with CABG alone. Group 2 patients (n = 36) received CABG plus TMR. TMR was performed in regions of nongraftable coronary targets. Indications for surgery in both groups were Canadian Cardiovascular Society angina scores III or IV and an ejection fraction > or = 30%. Exclusion criteria were an emergency procedure within 12 hours, unstable angina, or an acute myocardial infarction within 72 hours. Thirty-day outcomes of the two groups were compared. The means +/- SD of patient ages (63.3 +/- 1.6 years versus 65.4 +/- 1.4 years) and ejection fractions (51.6% +/- 0.9% versus 48.5% +/- 1.6%) were similar for the two groups. RESULTS: The number of grafts performed and operating room times for the two groups were similar (3.1 +/- 0.1 versus 2.9 +/- 0.1 and 276.7 +/- 4.4 minutes versus 272.3 +/- 10.7 minutes, respectively). Intensive care unit times and lengths of stay (emergency room to discharge) were significantly shorter in the CABG plus TMR group (2.1 +/- 0.2 days versus 1.6 +/- 0.2 days [P < .001] and 8.2 +/- 0.4 days versus 7.1 +/-0.6 days [P < .001], respectively). The 30-day readmission rate was lower in the CABG plus TMR group (7.8% versus 2.8%; P < .5). The frequency of atrial fibrillation was also significantly lower in the CABG plus TMR group (37.4% versus 16.7%; P < .025). Major adverse outcomes, such as reoperation for bleeding, respiratory failure, renal failure, stroke, and mortality were similar in the two groups, although there were no mortalities in the CABG plus TMR group. CONCLUSION: TMR as an adjunctive revascularization to CABG in selected patients with limited options may improve in-hospital outcomes.